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journal of
thejMedical
Society of
Autopsies: Newark City
Hospital
W.D. Sharpe, M.D.
Area Health Education
Center Program
M.A. Landay, D.D.S., et al.
Acute Radiation Pneumonitis
S. Silberstein, M.D., et al.
Table of Contents
Page 4
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VOL. 81— NUMBER 1— JANUARY 1984
THE MEDICAL SOCIETY
OF NEW JERSEY Founded July 23, 1766
Officers and Trustees
President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
President-elect
Frank Y. Watson, M.D. (Essex) Glen Ridge
First Vice President
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
Second Vice President
Edward A. Schauer, M.D. (Monmouth) Farmingdale
Immediate Past President
Howard D. Slobodien, M.D. (Middlesex) Metuchen
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Douglas M. Costabile, M.D. , C/7a/>wa/7( 1984) (Union) .. Murray Hill
Frank Campo, M.D. (1984) (Mercer) Trenton
Harry M. Carnes, M.D. (1985) (Camden) Audubon
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
John J. Crosby, Jr., M.D. (1984) Jersey City
Palma E. Formica, M.D. (1984) (Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985) (Salem) Carney’s Point
Frank Gingerelli, M.D. ( 1986) (Bergen) Hackensack
William Greifinger, M.D. (1984) (Essex) Belleville
John P. Kengeter, M.D. ( 1984) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Michael R. Ramundo, M.D. (1984) (Passaic) Clifton
Councilors
January 1984
Publication Committee
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R. Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1984) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A. Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Albert F. Moriconi, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1984) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia, M.D., Chairman (1985) Spring Lake
Alfred A. Alessi, M.D. (1984) Hackensack
Frederick W. Durham, M.D. (1984) Haddonfield
Palma E. Formica, M.D. (1984) New Brunswick
Karl T. Franzoni, M.D. (1984) Trenton
John S. Madara, M.D. (1984) Salem
Henry J. Mineur, M.D. (1984) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Stuart D. Cook, M.D. (Neurol)
Robert Dodelson, M.D. (Nephrol)
Wm. A. Dwyer, Jr., M.D. (Surg)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Arthur Goldfarb, M.D. (Allerg/Clin Immunol)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Joel D. Levinson, M.D. (Gastroenterol)
Henry R. Liss, M.D. (Neurosurg)
Geobel A. Marin, M.D. (Int Med/Gastroenterol)
Robby Meijer, M.D. (Plas Surg)
Christopher A. Papa, M.D. (Dermatol)
Victor Parsonnet, M.D. (Vase Surg)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A. Arthur Sugerman, M.D. (Psychiat)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except semimonthly
in July (13 issues), under direction of the Committee on Publication, by the Medical Society of New Jersey, Two Princess
Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA, by the Hughes Printing Co. Whole number of issues 958.
Member’s subscription ($10) is included in Society dues. Rates for nonmembers, $20; outside USA add $7.50 for postage.
Single copies, $2. Address communications to The Journal MSNJ, 2 Princess Road, Lawrenceville, NJ 08648, (609) 896-1766.
Second-class postage paid at Trenton, NJ, and additional entry office. Copyright 1984 by the Medical Society of New Jersey.
2
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VOL. 81— NUMBER 1— JANUARY 1984
January 1984
Journal of
the Medical
Society of
Z
America’s
First
Medical
Society
CONTENTS
7 MEMBERSHIP NEWSLETTER
13 PROFESSIONAL LIABILITY COMMENTARY
EDITORIAL
17 William Carlos Williams, M.D. — A Postscript
21 HOSPITAL GOVERNING BOARDS
26 JEMPAC REPORT
SPECIAL ARTICLE
31 AMA Principles of Medical Ethics
ARTICLE
37 The Area Health Education Center Program
M.A. Landay, D.D.S., B.L. Cohen, D.O., R.C. Reynolds, M.D., Camden
CASE REPORTS
43 Infantile Embryonal Carcinoma in Children
P.S. Affuso, M.D., and A.O. Fayemi, M.D., Teaneck
45 Peroral Esophageal Endoprosthesis for the Management of Incurable Esophageal
Carcinoma
M.N. Kalkay, M.D., B. Pancer, M.D., A. Derman, M.D., Holmdel
49 Acute Radiation Pneumonitis
S. Silberstein, M.D., D. Malcolm, M.D., E.V. Braun, M.D., A.O. Fayemi, M.D., Teaneck
MEDICAL HISTORY
53 Autopsies at Newark City Hospital, 1908 to 191 1
W.D. Sharpe, M.D., South Orange
63 PEDIATRIC BRIEFS
IMPAIRED PHYSICIANS PROGRAM
65 D.l. Canavan, M.D., Lawrenceville
DOCTORS’ NOTEBOOK
68 Trustees’ Minutes: November 20, 1983
69 President’s Column, Alexander D. Kovacs, M.D.
70 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
71 MSNJ Auxiliary, Mrs. Gale VJayman
71 AM NJ Report, Paul J. Hirsch, M.D.
71 New Members
72 Physicians Seeking Location in New Jersey
74 Housing Application
75 Medical Philately, Joseph A. Kler, M.D.
77 CME Calendar
81 Letters to the Editor
82 Obituaries
83 Book Reviews
85 Information for Authors
On The Cover: Our cover photograph.shows
a working Dr. Harrison S. Martland, a
pathologist at Newark City Hospital from
1908 to 1952. The medical history of
autopsies performed at Newark City Hospital
from 1908 to 1911 uncovers a wealth of ma-
terial; read the full story on page 53. Cover
photograph: UMDNJ, Archives/George F.
Smith Library, 100 Bergen Street, Newark,
NJ 07103.
mininwn— «Mi i
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Dr. S. Randy Sarantos is that professional.
A doctor with over 20 years of financial experience, who is now a
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retirement, and investing your pension assets.
Dr. Sarantos is a member of the International Association of
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6
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
THE MEDICAL SOCIETY OF NEW JERSEY VOLUME B
MEDICAID FACTS
Physicians frequently are criticized for Medicaid
abuse and the high cost of health care. An analysis of
Medicaid payments by service category in New Jersey
in 1973 and 1983 indicates physicians are not the cause
of the problem but like the patients have become vic-
tims of the system.
Physician reimbursement has dropped from 13.5
percent of the service budget in 1973 to 7 percent of
the service budget in 1983.
Physician reimbursement constitutes total payment
to physicians for all types of service, i.e. diagnostic,
therapeutic, medical, surgical, outpatient, and inpa-
tient.
In fiscal year 1983, hospital outpatient services were
reimbursed in the amount of $63 million. This ex-
ceeded total physician reimbursement by $6.3 million.
Medicaid’s response to this situation is the Personal
Physician Plan or “gatekeeper” concept that centers
on the primary care physician as a “case manager”
which pays the physician on a per capita basis and
places him at risk for services ordered.
MSNJ maintains the “gatekeeper” is not the answer.
Fair and reasonable fees to physicians for services
rendered in their offices is the only real answer. Every
other approach is simply an effort to avoid coming to
grip with the basic issue.
TABLE
Medicaid Payments
Fiscal Year
Fiscal Year
1973
1983
(millions)
(millions)
Hospitals
86.9
297.1
Nursing homes
76.3
278.4
Drugs
18.3
61.6
Other
30.7
99.4
Physicians
33.1
56.7
Total
$245,253,840
$793,180,750
NEW ECFMG EXAM
ECFMG plans to administer the new foreign medi-
cal graduate examination in the medical sciences
(FMGEMS) each January and July beginning in July
1984. The examination will consist of a one-day test
in the basic medical sciences and a one-day test in the
clinical sciences, both derived from the pool of ques-
tions in the basic and clinical sciences maintained by
the National Board of Medical Examiners. The
ECFMG English test will be given with each adminis-
tration of FMGEMS.
The final ECFMG examination in the present for-
mat will be given for the last time in January 1984,
and the final Visa Qualifying Examination was admin-
istered in September 1983.
Individuals attending medical schools listed in the
current edition of the World Directory of Medical
Schools may take the basic sciences component of
FMGEMS at the end of two years at the school, and
they may take the clinical sciences component when
they are within 12 months of completing the formal
didactic requirements of the medical school.
MEDICARE ASSIGNMENT —
FEE FREEZE
The American Medical Association strongly urged
Congress to reject provisions requiring physicians to
accept Medicare assignment and to roll back Medicare
physicians’ fees for hospital inpatient services. The
Association pointed out that the House Ways and
Means Committee already had rejected these two
proposals. The Association also strongly opposed
proposals to require hospitals to obtain agreements
from all members of its medical staff to accept assign-
ments for all Medicare inpatient services. (Letter to all
members of the House of Representatives, October 24,
1983)
MUTUAL PROTECTION
ASSOCIATIONS, S. 1745
The AMA supports S. 1745, a bill that would
provide tax-exempt status to physicians’ and surgeons’
mutual protection and indemnity associations provid-
ing malpractice insurance. The bill also provides that
initial payments made by a physician or surgeon to
VOL. 81— NUMBER 1— JANUARY 1984
7
such entities would be tax deductible as a business
expense. The bill represents a reasonable step towards
providing equality of tax treatment for this form of
providing essential professional liability coverage.
(Letter to Senator Robert Dole, Chairman, Senate
Finance Committee, October 25, 1983)
PATIENT RECORDS
The following is a letter sent to the State Board of
Medical Examiners on September 14, 1983, by the
Legal Counsel to MSNJ along with the complete text
of the Request for Declaratory Ruling:
Dear Doctor Riggs:
In reading through the June 8, 1983, minutes of the
State Board of Medical Examiners, I have noted that
the State Board listed a detailed format of record keep-
ing in a disciplinary action against a chiropractor.
A review of the New Jersey Administrative Code
and the New Jersey Statutes Annotated reveals that the
format for medical records required by the Board has
not been established by statute or regulation. There is,
therefore, uncertainty in the medical community as to
what the Board of Medical Examiners deems to be
adequate.
I am, therefore, submitting the enclosed request for
a declaratory ruling.
(signed) Vincent A. Maressa
Legal Counsel
Medical Society of New Jersey
Two Princess Road
Lawrenceville, New Jersey 08648
(609) 896-1766
Department of Law & Public Safety
Division of Consumer Affairs
State Board of Medical Examiners
Docket No.
In the Matter of the Request of the
Medical Society of New Jersey
for a Declaratory Ruling.
Request for
Declaratory Ruling
The Medical Society of New Jersey, with offices
located at Two Princess Road, Lawrenceville, New
Jersey, by way of a request for a declaratory ruling
pursuant to N.J.S.A. 52A4B-8, says:
1. On or about June 8, 1983, the State Board of
Medical Examiners found that a chiropractor, Howard
I. Cantor, D.C., was guilty of repeated acts of negli-
gence and malpractice when it found that Doctor Can-
tor failed to record in his patient records a complete
history, description of the examination rendered,
physical findings, a diagnosis on those physical find-
ings, a descripton of the treatment rendered during
each patient visit, and a notation of any progress made
by the patient from one visit to another. The Board
found that failure to make such patient records was
a deviation from accepted standards of chiropractic
practice.
2. The Medical Society of New Jersey is a pro-
fessional society which represents over 9,200 fully
licensed New Jersey physicians and surgeons.
3. The Medical Society denies the existence of any
statute or regulation which declares that a physician
or surgeon in the state of New Jersey is required to
keep records in the same fashion as those required by
the Board of Medical Examiners with respect to
chiropractors.
4. No action is pending in any court involving the
matters herein in dispute.
Wherefore, plaintiff requests a declaratory ruling
whereby the State Board of Medical Examiners shall
set forth that a physician in the state of New Jersey
is not required to maintain patient records in the same
fashion as chiropractors.
Dated: September 14, 1983
Medical Society of New Jersey
By: Vincent A. Maressa
Legal Counsel
The following response dated November 14, 1983,
has been received from the State Board of Medical
Examiners and is printed at their request and for your
information and guidance:
Dear Mr. Maressa:
On behalf of the Medical Society of New Jersey, you
have submitted a Request for Declaratory Ruling re-
garding the keeping of medical records by physicians.
You assert that there is no “statute or regulation which
declares that a physician or surgeon in the state of New
Jersey is required to keep records in the same fashion
as those required by the Board of Medical Examiners
with respect to chiropractors” and you ask the Board
to agree with that statement, as if that statement per-
manently settled the implied matters raised in your
letter. Your cover letter of September 14, 1983, states
that the “format for medical records required by the
Board has not been established by statute or regu-
lation.”
We make several observations at the outset:
1) Your request sets forth certain elements of a
patient’s record which purport to be those held by the
Board in the case of in re Cantor, D.C. to be required
of a chiropractor. Your list, however, not only fails
to include all the elements set forth in the Board’s
Order in that case, but also changes the wording in
a manner which materially alters the sense of the
Order. For example, you omitted reference to x-ray
findings — which can be a very important aspect of
chiropractic practice, and required inclusion of that
data in the diagnosis and treatment plan. This is sig-
8
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
nificant because the fundamental thrust of the Board
Order in that case was to stress the theory of scientific
method as applied to a professional practice — where
pertinent — and a rationale in patient management.
2) The “format” of a record, to which you refer,
relates more to form and organization than to substan-
tive content, and therefore is not particularly relevant
to the subject at hand, except where substance is
absent.
3) The scope of practice of a licensed chiropractor
is vastly different from that of a licensed physician or
surgeon. The records of a Doctor of Chiropractic must
therefore inevitably contain certain minimum data
which will not necessarily be part of the record of a
Doctor of Medicine or a Doctor of Osteopathic Medi-
cine, and vice versa.
Thus, it is clear that the question you pose actually
answers itself — and yet is not the significant question
at all. We shall assume that the real question you pose
is this: Is there a mandatory minimum content to a
physician’s patient record and if so, what is it and by
what standard is it imposed?
It is clear that neither the Legislature nor the Medi-
cal Board has deemed it necessary thus far to adopt
a law or rule specifying the answer to your question.
This is because the answer is found in the standards
of accepted practice in the profession, and as carried
out in the various specialties. Modern medical schools
teach the practice of medicine and surgery based upon
the scientific method. That method presumes —
certainly on the part of persons licensed in this state
and, we believe, generally across the country — that the
physician has studied and acquired a significant fund
of knowledge of anatomy, biology, physiology, neu-
rology, chemistry, physics, pharmacology, psychology,
etc. The profession of medicine expects that the
plenary-licensed physician will bring the study of these
sciences to bear upon the total condition of each pa-
tient presenting with a complaint. It is the doctor’s task
to receive and make a record of the subjective com-
plaints that brought the patient to seek treatment; to
consider what physical and psychological examination
seems indicated, both minimally and particularly, in
light of the problem presented, based upon the doc-
tor’s training and experience. The doctor must then
effectuate the appropriate examination and record the
findings. If the doctor believes x-rays are warranted,
in spite of their recognized risk, in order to make a
proper diagnosis, then a proper performance of the x-
ray procedure is expected, as is a report of the findings.
Similarly, if subjective and clinical findings make lab-
oratory studies advisable, it is expected that they will
be properly performed and evaluated, and the results
integrated into the doctor’s diagnosis. Where surgery
is involved, consultation may, on occasion, be ap-
propriate, and should be reflected in the record.
If, in the treatment plan, medication is deemed
necessary, it is expected that the physician will make
careful determination of the indications and contrain-
dications, and will appropriately inform the patient of
the treatment goals, risks, and cautions. When a Con-
trolled Dangerous Drug is the drug being prescribed,
extra care must be taken. Because of the abuse poten-
tial of these drugs, the physician is expected to be
particular in recording the drug prescribed, its quanti-
ty, dosage unit and frequency, and the date the
prescription is issued. The physician must comply also
with all pertinent rules of the Department of Health
and of the Board of Medical Examiners and federal
government respecting utilization of the drugs them-
selves and record-keeping requirements. Clearly, cer-
tain administrative procedures have been ordered by
rule because of the inherent dangers of these
drugs — which have been magnified by careless prac-
tices on the part of some physicians. Other require-
ments are simply codifications of the good general
practices dictated by common sense.
We need not address the necessity of patient in-
formed consent to the examination to be conducted,
and the treatment to be given. These issues have been
amply dealt with in medical training, in common sense,
and in widely publicized cases indicating the conse-
quences of failure to assure adequate communication
and agreement between physician and patient. Where
significant treatment risks are involved, good practice
would seem to require that patient consent be included
in the record.
In short, the content of the physician’s patient re-
cord is established by standards of accepted medical
practice pertaining both to general practice and to a
specialty, as appropriate. Physicians recognize that
medical practice always involves a reception, examin-
ation, and evaluation of subjective complaints, objec-
tive findings, analysis, and treatment plan — whether it
be in the area of general practice or psychiatry. A
current rule of the Medical Board, N.J.A.C. 13:35-6.5,
requires that a patient record be prepared and main-
tained for seven years from date of last entry. Sections
(b) and (c) of that rule make clear that a patient record
is expected to include objective data as well as a nonob-
jective data portion.
The making of a written record is of assistance to
the busy physician — who may not remember on a
subsequent visit observations or findings which seemed
significant — or unexplained — on a prior visit. It is of
assistance when reviewed retrospectively, to perceive
a general pattern of behavior which may have
diagnostic or prognostic significance. It is important
for the substantial portion of our population which is
transient, for the patient who is moving and needs to
carry to the next health care professional a proper and
complete medical history, to avoid costly trial and
error in treatment. Finally, we must recognize that a
written record may be significant in the course of in-
quiry or even litigation, where the appropriateness of
the treatment has been called into question. A doctor
best can protect the integrity of the medical treatment
process by having noted the significant elements of the
VOL. 81— NUMBER 1— JANUARY 1984
9
treatment. These concerns do not require the writing
of a book on the occasion of each patient visit; but
they do warrant the recordation of basic data and all
such other data as medical training and experience
teach us are significant in aiding us to bring to bear
our special training in order to provide good medical
care to our patients.
In summary, standards of accepted practice estab-
lish the proper content of the physician’s medical rec-
ord on each patient. Where the state or federal govern-
ment, or administrative agencies, have found ad-
ditional or more explicit requirements to be necessary,
they have been promulgated by law or rule, and it is
the obligation of each licensee to remain current with
respect to law and rules applicable to that licensed
profession. Professional societies can certainly aid
their memberships in this regard, by calling particular
notice to new rule proposals and adoptions and to
legislation. It is for that reason that the Board of
Medical Examiners has regularly invited representa-
tives of the Medical Society of New Jersey to attend
the public meetings of the Medical Board, in hope that
the representatives will carry back to the membership
news of importance in the development of the pro-
fession.
We trust that this letter answers the direct and in-
direct questions in your cover letter and Request for
Declaratory Ruling. As your questions were submitted
on behalf of the membership of your Society, we an-
ticipate that you will make the Board’s views available
to the entire membership.
Yours truly,
(signed) Edwin H. Albano, M.D.
President
NJ State Board of Medical Examiners
MARKETING STRATEGIES
FOR PRIVATE PRACTICE
The traditional ways of practicing medicine in the
United States have been undergoing a transition for
several years.
The manner in which health service is being offered
with its multiple modalities is confusing and somewhat
threatening even to people who have been practicing
for many years.
The new doctors coming into practice are con-
fronted with various delivery systems of medical care
that they will be forced to contend with. The estab-
lished older physicians need to be made aware of the
changes that have taken place and what effect it will
have on their future.
As a service to its membership, MSNJ is willing to
cosponsor a program on coping with these changes in
conjunction with the AMA Department of Practice
Management.
The subject matter of the program would cover
medical marketing, how to meet patients’ needs, and
planning for changes coming from business, govern-
ment, and the insurance industry. The planning for
changes in health care delivery systems and changes]
in hospital/physician relationships will be discussed.
The professional relations necessary to maximize
patient satisfaction will be included and cover dealing]
with patients on a one-on-one basis.
Pricing of services with a look at your options andi
how to communicate credit and fee policies clearly will
be discussed.
The mobility of the American people resulting in
population shifts brings about changes in medical
practicing opportunities. Deciding where you will
locate or relocate is important to your professional
success and this will be covered.
Practice viability is vitally important. Community
involvement, community service, and proper advertis-
ing will be part of the program.
The workshop will allow ample time for group ques-
tions and answers.
The cost of this all-day session will be $100 to cover
the expenses of the speakers and food. This is a tax-
deductible expense. If 20 members or more write
MSNJ indicating their interest in the workshop, we
will make it available at the Executive Offices.
MEDIA TECHNIQUES’ SEMINAR
The Council on Public Relations and MSNJ are
aware of the necessity of enlightening our membership
with the proper procedures for dealing with the various
media. This especially is true for those physicians who
aspire to leadership positions in the medical pro-
fession.
The Medical Society of New Jersey will be offering
its second Media Techniques Seminar at the Executive
Offices, Two Princess Road, Lawrenceville, on
Wednesday, March 21, 1984, from 9 A.M. to 4:00 P.M.
Luncheon will be served. The registration will be lim-
ited to the first 50 applicants. There will be a fee of
$30 to cover expenses and lunch. This is a tax-deduc-
tible expense and a worthwhile experience.
This seminar is an excellent opportunity to learn
how to handle media interviews and gain exposure to
the various public relations techniques. Outstanding
media personalities will be participating in this sem-
inar. There will be ample opportunity for questions
and answers and role play sessions.
HEALTH CARE FOR THE
UNEMPLOYED AND NEEDY
The Society’s Council on Medical Services feels that
substantial unemployment, along with reductions in
Medicaid and disability programs, continue to make
it difficult for increasing numbers of people to obtain
necessary health care. Because of the need further to
address the problem of health care for the unemployed
and needy, the AMA has requested the distribution of
a letter designed to be utilized by physicians, with
10
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
modifications to fit their office letter format and style,
for distribution to their patients (Figure). The purpose
is to make patients aware of the physician's desire to
respond to the economic hardship of his unemployed
and needy patients through provision of necessary
medical care on a free or reduced fee basis or through
creation of other appropriate financial arrangements.
Physicians also are urged to continue to discuss with
local hospitals ways to allow for necessary hospital-
ization for those who have lost their health insurance
because of unemployment or changes in eligibility or
coverage for Medicaid or disability programs.
FINI
No talent or record of achievement is necessary to
criticize another.
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the “con-
spiracy of silence” that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle” on a suffering colleague is indeed an ACT OF LOVE!
Call Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
1 1
Dear Patient:
At a time when substantial unemployment, along with re-
ductions in Medicaid and disability programs, continue to
make it difficult for increasing numbers of people to obtain
necessary health care, I want to assure my patients that such
circumstances will not be a barrier to my provision of neces-
sary medical services.
I believe it is important that you continue to receive the
medical care you need. Provision of the best medical care
possible, as always, is my primary goal in serving my pa-
tients.
If you would have difficulty in paying my bills because of
unemployment and a loss of health insurance or due to a
cutback in Medicaid or disability program, please let me or
my staff know. We can make arrangements to provide for
necessary care on a free or fee-reduced basis, or make other
financial arrangements.
Most importantly, do not hesitate to seek my services be-
cause you are having financial problems beyond your con-
trol. Please let me or my office staff know if you would like
to discuss my policy on this further. Sincerely,
VOL. 81— NUMBER 1— JANUARY 1984
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•PROFESSIONAL LIABILITY COMMENTARY*
Court Decisions
The Appellate Division of the Su-
perior Court of New Jersey held
that a lower court had erred in or-
dering the removal of a nasogastric feeding tube from an 84-
year-old nursing home patient {In Re Conroy, 190 N.J.
Super. 453, App. Div. 1983).
The patient, Claire Conroy, suffered from severe organic
brain syndrome, decubitus ulcers, diabetes, and arterioscler-
osis. Her only living relative, a nephew, petitioned the court
to authorize the removal of the tube after Ms. Conroy’s
treating physician refused to do so.
The lower court ordered the tube removed but its decision
was appealed immediately and the tube was not removed.
The patient died two weeks after the lower court’s order was
issued.
The Appellate Division of the Superior Court held that
the lower court erred in ordering the removal of the tube.
It said that the removal of the tube would cause death by
dehydration and starvation and would violate a basic prin-
ciple of medical ethnics, “to do no harm.” The court said
that the decision to remove life support should be limited
to those patients who are incurable and terminally ill and
who are irreversibly comatose or vegetative. It said, “to
allow a physician or family member to disconnect life-sus-
taining treatment to a person solely because that person's
lack of intellectual capacity precludes her from enjoying a
meaningful quality of life would establish a dangerous prece-
dent that logically could be extended far beyond the facts
of the case before us.” The Supreme Court of New Jersey
had agreed to hear the Conroy case. As of this writing, the
state’s highest court has not yet issued its opinion.
CAN THE OBSTETRICIAN DOCUMENT REASONS
FOR DECISIONS?
A practical tip from a clinician-academician could help
obstetricians guard against possible “bad baby” claims. His
suggestion is to make sure fetal monitoring done during
labor and delivery, whether by auscultation or electronically,
is recorded.
“Nurses generally can monitor a patient in labor as well
as the equipment can,” said Clark Miller Hinkley, M.D.,
chief, department of obstetrics, Baylor College of Medicine.
“But if it isn’t recorded, (as far as the courts are concerned)
you didn’t do it. That’s one of the major problems in (baby)
cases today. The plaintiff contends that the physician didn’t
adequately monitor labor.”
The malpractice threat has stimulated many physicians to
provide better records, Dr. Miller said, but added, “I see a
lot of them who are not properly documenting what hap-
pened. Doctors take shortcuts in paperwork, because there’s
so much of it, and I don’t know how we can get around
it.”
Should an obstetrician store all the tapes when electronic
fetal monitoring is used? A busy obstetrician could fill a
room with the miles of tape generated, Dr. Miller pointed
out. Here’s his solution:
"I put an interpretation of the monitoring slip in the chart
right after delivery and then I throw the tape away, just as
the doctor who takes an EKG usually does.”
Dr. Miller was not making a case for electronic fetal
monitoring, except with high-risk patients or when there are
ominous indications during labor that call for internal fetal
monitoring. Referring to a Denver study by Albert
Haverkamp, M.D., Dr. Miller said there are times when
electronic monitoring can lead to performance of unneces-
sary cesarean sections.
It was the conclusion of Haverkamp that the monitoring
pattern does affect the method of delivery “despite the fact
that these data indicate very little predictive value in the
pattern.” Dr. Haverkamp, with James R. Murphy, M.D.,
and other associates at Denver General Hospital, studied the
relation of electronic fetal monitoring patterns to infant out-
come measures and stated that considerable work needs to
be done before they can be used reliably as an indicator of
infant distress. In addition, Haverkamp concluded, “Studies
need to be conducted which separate chronic, morbid fetal
conditions which lead to ominous patterns from acute fetal
distress during labor.” (Medical Liability Monitor, Vol. 8,
No. 7, July 29, 1983)
FLORIDA APPEALS COURT UPHOLDS $12 MILLION
AWARD BUT CUTS ATTORNEY’S BIG FEE
A Florida district appeals court has upheld a $12.47
million jury award — the largest in the state's history — to a
comatose woman who suffered brain damage in a
Lauderdale Lakes hospital, but has reduced an award of $4.4
million in legal fees to the plaintiff s attorney in the case.
The West Palm Beach Appeals Court reduced Sheldon J.
Schlesinger’s award under a two-year-old state law that calls
for the loser in a medical malpractice suit to pay “reasonable
attorney’s fees” to the winner to $1.5 million.
*This item from the Department of Professional Liability Control,
MSNJ, was prepared by James E. George, M.D., J.D., and A.
Ronald Rouse who are, respectively. Director of the Department
and Director of Special Projects.
VOL. 81— NUMBER 1— JANUARY 1984
Schlesinger still could collect a contingency fee from the
family of Susan Von Stetina of between 30 and 50 per-
cent— or between $4 million and $6 million — in addition to
the court-awarded $1.5 million. Schlesinger, who has ob-
tained seven jury verdicts in excess of $1 million, reportedly
charges a standard 40 percent contingency fee and as much
as 50 percent if the case is appealed.
Susan Von Stetina, 30, suffered irreversible brain damage
and now is in a permanent coma when a respirator at Florida
Medical Center failed in the night and the malfunction was
not discovered until morning. She had undergone surgery
following an auto crash.
In March 1982, a Broward County Circuit Court jury
awarded Ms. Von Stetina $7.5 million for lifetime medical
costs and care, and $5 million for pain and suffering. Ap-
pellate Judge Gavin K. Letts, likened her state to “the tor-
tures of the damned,” and said she was entitled to the award.
Florida Medical Center and the state’s Patient Compensa-
tion Fund say they will appeal the award to the Florida
Supreme Court. Florida sources say the fund has half of its
assets pledged in this case and somewhere between $125
million and $175 million pending in unpaid claims. The PCF
stopped writing protection for physicians and hospitals in
late June. (Medical Liability Monitor, Vol. 8, No. 8, August
29, 1983)
DID YOU KNOW . . .
The trend toward million-plus jury awards is accelerating,
claims Jury Verdict Research Inc. which tracked a total of
536 personal injury suits with high payouts? Significantly,
one-third were made in the past three years.
St. Paul Companies report that their insured doctors are
averaging 4.8 claims per 100, up from 2.9 per physician in
1975?
WHERE MALPRACTICE SUITS ARE MOST LIKELY
TO OCCUR
More than 25 percent of all malpractice claims against
physicians stem from surgery-related incidents, according to
a study of claims incurred by the nation’s largest medical
liability insurer, St. Paul Fire and Marine Insurance Co.
(Table). The highest awards for damages, however, are made
on claims for birth-related problems resulting from improper
treatment. (Medical Economics, September 19, 1983)
TABLE
Top 15 Malpractice Claims Against Physicians (1982)
Number of Claims
541
245
207
Nature of Claim
Postoperative complications
Improper birth-related treatment
Failure to diagnose fracture or
dislocation
Inadvertent act during surgery
Inappropriate surgical procedure
Failure to diagnose cancer
Improper treatment of fracture or
dislocation
Failure to diagnose infection
Improper treatment of infection
Improper treatment involving drug
side effects
Failure to diagnose pregnancy-
related problems
Lack of treatment supervision
Insufficient therapy treatment
Postoperative death
Improper treatment during
examination
191
168
144
120
109
109
108
103
97
86
79
71
DOCTORS REFUSE TO BUY INSURANCE; MICHIGAN
HOSPITAL REVOKES PRIVILEGES
Exercising a right which the courts around the nation
increasingly have upheld, a Michigan hospital recently re-
voked staff privileges of three physicians who refused to buy
malpractice insurance on grounds that it was too costly.
Early in June, Sinai Hospital, Detroit, sent warning letters)
to about 25 of the nearly 800 physicians on staff advising
them that they could not continue to practice in the institu-
tion without proof of malpractice insurance. When the cut-)
off date passed in late June, 3 physicians immediately were
dropped. Fourteen of a possible 16 physicians filed suit in
Wayne County Circuit Court, but Judge Roland Olzark
refused their request for a temporary restraining order to
block the dismissals.
Originally, the hospital stipulated that each doctor must
carry $ 1 /$ 1 million in coverage, but the amount was reduced
to $200,000/$600,000 after complaints by physician staff
members. (Medical Liabiility Monitor, Vol. 8, No. 7, July
29, 1983)
14
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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15
© 1983 Health Wavs Inc.
Henry Mineur, M,D., Card
Speaker of the House of Delegates of the Medical
;ist, Cranford,
;ty of New Jei
"Sadly, as the cost of medical
care increases and the scope of
many health insurance pro-
grams decreases, my patients
wind up in a terrible squeeze.
I found a very satisfactory solu-
tion. I became a participating
physician in Health Ways.
With HealthWays, I can prac-
tice the kind of medicine that
will truly benefit my patients
without worrying about their
financial positions because of
the HealthWays unique physi-
cian reimbursement policy.
That's a significant plus.
In addition, the administra-
tive and financial structure of
HealthWays is fighting the as-
tonishing escalation of costs by
covering procedures easily done
on an out-patient basis rather
than in the hospital. That makes
a lot of sense. So does their
policy of covering routine
check-ups. And since the bills
go directly to HealthWays, the
specter of unpaid bills is elimi-
nated."
HealthWays can be most valu-
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more information, call Jon Mar-
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or 609-394-1995.
HealtliWays
THE WAY TO BETTER V HEALTH CARE.
16
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
EDITORIAL
William Carlos Williams, M.D. — A Postscript
On Sunday, September 11, 1983, a group of physicians,
irtists, composers, professors, authors, and their spouses and
'riends, gathered in Princeton to “celebrate a man, a physi-
cian, and a poet, on the 100th anniversary of his birth."
[Poems were read. Anecdotes of personal encounters with
Williams were recited.
Arthur Krosnick, M.D.
The highlight was the comment of William Eric Williams,
M.D., who lives and practices pediatrics at 9 Ridge Road,
Rutherford, the home and office of his father, William
Carlos Williams, M.D. (1883-1963). A.K.
“ ‘The Use of Force’ carries in it probably all of pediatrics
in a nutshell. “Williams's short stories . . . say as much about
pediatrics, which is my work, as anything I've ever seen
written.” Avrum L. Katcher, M.D.
Avrum L. Katcher, M.D.
“When I first read 'The Sparrow’ (a poem dedicated by
William Carlos Williams (to my father) many years ago), I
really was moved by it. The final image of the poem is the
one I tried to make a painting of. I made some drawings
and studies; then, finally, I started working on a painting
of this dead sparrow lying in the road. I just couldn’t make
it work, so I just put it away. About a year later, I was
looking for something on which to paint, and I had com-
pletely forgotten what was on this panel. It was just a white
panel to me. I put it up on the easel, and I started making
a self-portrait. In the process, all of a sudden, to my surprise,
this bird came up over my head. I called this self-portrait,
The Sparrow.” Henry Niese
Bill Smith and Henry Niese
“Dr. Williams sent most of his patients to the Passaic
General Hospital, but occasionally he did come to St. Mary’s
Hospital. One day, I was introduced to the great man. I had
just finished reading Paterson, and I told this august individ-
ual that I'd just finished reading this wonderful poem. He
was a taciturn person, and he didn't react very strongly, but
he did turn to me and say, 'My God, you deserve a medal
of honor for reading that junk!' He was surprised that any
young person would wade through that great epic.”
Morris H. Saffron, M.D.
Morris H. Saffron, M.D.
VOL. 81— NUMBER 1— JANUARY 1984
17
“As I became acquainted with him, there were many
admirable things about Williams. The one I would choose
would be his persistence. When he started as a poet in the
1910s and 1920s, it was a period of great experimentation.
People were doing all sorts of strange and in some cases,
like Williams, really very wonderful things, all kinds of new
James Guimond, Ph.D.
forms. He also was persistent in the way he could shift his
creativity, not only between medicine and literature, but also
within literature itself. When he started having trouble — like
most poets — with dry periods, he would start writing prose.
For example, he produced the wonderful short stories which
he started writing in the 1930s. At first he did this because
the poetry was coming very slowly.”
James Guimond, Ph.D.
“'The Widow's Lament in the Springtime’ was written in
1922. I came across it basically not only as a result of having
read a great deal of William Carlos Williams, but also be-
cause of that famous book by Yvor Winters called Primi-
tivism and Decadence, in which he analyzed this poem. When
I met William Carlos Williams, at the Brandeis Creative Arts
Milton Babbitt
Festival (very likely in 1957), there were poetry readings of
Williams's writing. I was involved in the musical aspects of
it. We sat and talked quite a bit about this analysis of
Winters, which Dr. Williams may have remembered. After
I set to music ‘The Widow's Lament’ it was performed first
here in Princeton by Bethany Beardsley, a soprano, at the
time of a memorial service for the first chairman of the
Princeton Music Department, Roy Dickinson Welch.”
Milton Babbitt
“I think your Journal is very successful — the issue is ter-
rific—the people did a great job. It's been quite a year for
me — with this climax now of the issue of The Journal. The
Dr. and Mrs. William Eric Williams and Henry Niese
following is part of the foreword to a new biography (in
press) by Leo Baldwin:
“His life’s work was poetry, his avocation — medicine.
“Poetry became his addiction, his habit, the gyroscope
that kept him on an even keel when the going got rough.
He found poetry everywhere, no need to search, just keep
the receptors uncluttered and let it come to you. Get it down
while it's hot, no garble, no distortion, nothing artificial. I’m
sure he was familiar with the old orthopedic adage, ‘splint
it where they lie.' To the physician this means to immobilize
the fracture before the patient or some well-meaning
Samaritan damages the injured part further. He would prac-
tice this in his own poetry. When an old woman takes a plum
from a wrinkled paper bag and relishes its flavor and juici-
ness, say so. When a cat climbs over a jam closet, putting
its paws precisely, rhythmically, into some clay pots, say so.
If some bawdy dancers with big cans, hips, and breasts shake
the joint as they go round, and round, and round, say so.
And he did! He was a capable and respected physician, he
was an accurate and honest reporter in his poetry. The
trained observer physician complemented the vibrant imagist
in the poet. Either occupation for most men would be a full-
time job. Fortunately, he had an inexhaustible flow of energy
that made it possible to do both jobs well — the doctor
nurtured the poet through his privileged admission into the
lives of his patients, the poet returned into the physician the
distillate of his observations, making the doctor a more
humane and altruistic minister to the sick. But, it was a
lonely existence, I suspect. There was little time or energy
left once the poet and the physician had been sated. He was
exploring new frontiers — a frontier always is scantily popu-
lated. He was overthrowing or attempting to overthrow a
tradition. He took the bit in his teeth, kicked over the traces,
and galloped for the horizon.” William E. Williams, M.D.
18
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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20
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
HOSPITAL GOVERNING BOARDS*
AMA House of Delegates’ Actions
Hospital governing board members
include a minority of physicians, yet
the decisions made closely embrace
the professional lives of the hospital’s medical staff. Since
the American Medical Association is one of the organized
voices of American physicians, it behooves the hospital gov-
erning board to be cognizant of AMA policies, just as the
hospital governing board must study the platforms of the
American Hospital Association and the myriad official
health-regulating agencies that impact on the health indus-
try.
At its 1983 Annual Meeting, the House of Delegates of
the AMA debated many resolutions, but adopted as policy
six which pertain to issues of interest to hospital medical
staffs and thus to governing boards as well.
Physician Credentialing: “Resolved, that the American
Medical Association recommends that hospital medical
staffs adopt bylaws which enable such medical staffs to retain
the prerogative and responsibility, as granted by the hospital
governing body, for credentialing all physicians and other
licensees who apply for clinical privileges, including those
who seek to enter into contractual arrangements with hospi-
tals.”
In this column (October 1983), Dr. James E. George point-
ed out the pitfalls of credentialing and the potential legal
ramifications of the process as it affects the hospital and its
governing board. It seems quite logical that the essence of
credential review is that of “peer review.” Who is better
qualified to evaluate physicians and other health pro-
fessionals who provide clinical services?
Open Nomination and Election for Medical Staff Officers:
“Resolved, that the American Medical Association supports
the right and responsibility of hospital medical staffs to have
an open and democratic nomination and election process for
medical staff officers.”
Although the hospital governing body retains unto itself
the final judgment as to who shall be officers of the medical
staff through an approval process, it clearly would be in-
imical for the board to reject the elected officers without
overwhelming evidence of misfeasance in the elective proc-
ess. Representation of the governing board may and should
observe the elective process, but the likelihood of
shenanigans is small.
Confidentiality in Medical Staff Peer Review: “Resolved,
that the American Medical Association encourages medical
staff peer review committees when evaluating the pro-
fessional practices of fully licensed physicians to consider
excluding nonphysicians.”
Confidentiality, through computer intrusion, “right to
know” concepts, and the urgency to record every word lest
a potential medical-legal confrontation arise, has been shat-
tered irreparably. However, common sense dictates that the
complexities of medical-surgical practice are beyond the ken
of the nonphysician observer in a peer review climate to
process unfamiliar data and come out with a balanced evalu-
ation. “Trials” by the news media based on inadequate infor-
mation, ineptitude, and bias, have virtually made a shambles
of the American jury system. In the interest of fair play,
medical staff peer review committees may serve their hospital
and its clients better by meeting in executive session when
sensitive matters which may be misinterpreted are discussed.
Bylaws, Rules, and Regulations: No Incorporation by Refer-
ence: “Resolved, that the American Medical Association
encourages medical staffs to develop their own bylaws, rules,
and regulations and not to incorporate other documents by
reference.”
The hospital governing body has its own bylaws and the
hospital medical staff has a constitution, rules, and regu-
lations. It is obvious that conflicts between the staffs canons
and those of the Board of Directors can be resolved by the
latter by fiat. It equally is obvious that the staff can avoid
conflicts by accepting the governing body’s prescripts as its
own in a mindless fashion. Neither of these choices is de-
sirable in these days of fluidity in the science, technology,
and economics of medicine and health services. The hospital
medical staff, being aware of the consequences of new con-
cepts, new developments, and new relationships, must be free
to govern itself within those constraints that are essential.
Rules and regulations, as they pertain to patient care, must
be subject to revision and fine tuning. The physician must
retain this prerogative and responsibility.
Incorporation of Medical Staffs: “Resolved, that the
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, J.D., Ex-
ecutive Director, MSNJ; and James E. George, M.D., J.D., Director
of the Department of Professional Liability.
VOL. 81— NUMBER 1— JANUARY 1984
21
American Medical Association investigates all aspects of the
incorporation of medical staffs and report back to the House
of Delegates at the 1984 Annual Meeting.”
Why should a hospital medical staff consider incorpora-
tion? Why, indeed, should the modern hospital be a corpor-
ation and why should the individual practitioner be in-
corporated? The reasons for each of these facts of life in
America are manifold and complex. They are related to tax
laws, security for the future, and protection of the individual.
A hospital medical staff tends to appear like an amorphous,
faceless, ever-changing group of professionals whose individ-
ual contributions to the hospital and its patients are limited
by time, health, and other factors. The AMA reference com-
mittee “believed that the merit of this concept should be
studied before the AMA developed bylaws or assisted medi-
cal staffs in efforts to incorporate.” Obviously, medical staffs
are free to consider incorporation without the AMA inter-
vening; therefore, hospital governing boards should be aware
of this consideration.
Legal Counsel for Hospital Medical Staffs: “Resolved, that
the American Medical Association encourages medical staffs
to consult with their own attorneys or those of their county
medical society, state medical society, and/or AMA in secur-
ing knowledgeable legal counselors as appropriate.”
Most physicians, individually and in groups, are not law-
yers, yet many of their professional activities, their decisions,
and their problems as a hospital staff may have legal implica-
tions. Balanced judgment would suggest that the medical
staff should seek its own legal counsel rather than to utilize
the hospital corporation’s legal advisors. In fact, it would
appear that the latter may have a conflict of interest and
should step aside and encourage the medical staff to consult
its own attorney.
Hospital governing boards and medical staffs are powerful
groups made up of educated, intelligent, and successful men
and women. Shared ideas should help strengthen mutual
respect and cooperation.
A.K.
22
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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References:
1 . Stone PH, TuriZG, Muller JE: Efficacy of nifedipine therapy for refractory angina
pectoris. Am Heart J 104:672-681, September 1982.
2. Antman E, Muller J, Goldberg S, et al: Nifedipine therapy for coronary-artery
spasm: Experience in 127 patients. N Engl J Med 302:1269-1273, June 5, 1980.
BRIEF SUMMARY
PROCARDIA " (nifedipine) CAPSULES For Oral Use
INDICATIONS AND USAGE: I. Vasospastic Angina: PROCARDIA (nifedipine) is indicated for the
management of vasospastic angina confirmed by any of the following criteria: 1 ) classical pattern
of angina at rest accompanied by ST segment elevation, 2) angina or coronary artery spasm pro-
voked by ergonovine, or 3) angiographically demonstrated coronary artery spasm In those patients
who have had angiography, the presence of significant fixed obstructive disease is not incompatible
with the diagnosis of vasospastic angina, provided that the above criteria are satisfied. PROCARDIA
may also be used where the clinical presentation suggests a possible vasospastic component but
where vasospasm has not been confirmed, e g , where pain has a variable threshold on exertion or
in unstable angina where electrocardiographic findings are compatible with intermittent vaso-
spasm, or when angina is refractory to nitrates and/or adequate doses of beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated for
the management of chronic stable angina (effort-associated angina) without evidence of vasospasm
in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrates
or who cannot tolerate those agents.
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controlled
trials of up to eight weeks duration in reducing angina frequency and increasing exercise tolerance,
but confirmation of sustained effectiveness and evaluation of long-term safety in those patients are
incomplete
Controlled studies in small numbers of patients suggest concomitant use of PROCARDIA and
beta blocking agents may be beneficial in patients with chronic stable angina, but available infor-
mation is not sufficient to predict with confidence the effects of concurrent treatment, especially in
patients with compromised left ventricular function or cardiac conduction abnormalities. When in-
troducing such concomitant therapy, care must be taken to monitor blood pressure closely since
severe hypotension can occur from the combined effects of the drugs (See Warnings. )
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect of
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol-
erated hypotension These responses have usually occurred during initial titration or at the time of
subsequent upward dosage adjustment, and may be more likely in patients on concomitant beta
blockers.
Severe hypotension and/or increased fluid volume requirements have been reported in patients
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypass
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to be
due to the combination of PROCARDIA and a beta blocker, but the possibility that it may occur with
PROCARDIA alone, with low doses of fentanyl, in other surgical procedures, or with other narcotic
analgesics cannot be ruled out In PROCARDIA treated patients where surgery using high dose
fentanyl anesthesia is contemplated , the physician should be aware of these potential problems and .
if the patient's condition permits, sufficient time (at least 36 hours) should be allowed for
PROCARDIA to be washed out of the body prior to surgery.
Increased Angina: Occasional patients have developed well documented increased frequency, du-
ration or severity of angina on starting PROCARDIA or at the time of dosage increases The mech-
anism of this response is not established but could result from decreased coronary perfusion
associated with decreased diastolic pressure with increased heart rate, or from increased demand
resulting from increased heart rate alone
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with-
drawal syndrome with increased angina, probably related to increased sensitivity to catechol-
amines Initiation of PROCARDIA treatment will not prevent this occurrence and might be expected
to exacerbate it by provoking reflex catecholamine release There have been occasional reports of
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation It is important
to taper beta blockers if possible, rather than stopping them abruptly before beqinninq
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed heart
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater risk for
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascular
resistance, careful monitoring of blood pressure during the initial administration and titration
of PROCARDIA is suggested Close observation is especially recommended for patients already
taking medications that are known to lower blood pressure. (See Warnings.)
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso-
dilation and not due to left ventricular dysfunction, occurs in about one in ten patients treated with
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diuretic
therapy With patients whose angina is complicated by congestive heart failure, care should be taken
to differentiate this peripheral edema from the effects of increasing left ventricular dysfunction
Drug interactions: Beta-adrenergic blocking agents. (See Indications and Warnings.) Experience
in over 1400 patients in a non-comparative clinical trial has shown that concomitant administration
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasional
literature reports suggesting that the combination may increase the likelihood of congestive heart
failure, severe hypotension or exacerbation of angina
Long-acting nitrates PROCARDIA may be safely co-administered with nitrates, but there have
been no controlled studies to evaluate the antiangmal effectiveness of this combination.
Digitalis Administration of PROCARDIA with digoxin increased digoxin levels in nine of twelve
normal volunteers The average increase was 45% Another investigator found no increase in di-
goxin levels in thirteen patients with coronary artery disease In an uncontrolled study of over two
hundred patients with congestive heart failure during which digoxin blood levels were not meas-
ured, digitalis toxicity was not observed Since there have been isolated reports of patients with
elevated digoxin levels, it is recommended that digoxin levels be monitored when initiating, adjust-
ing, and discontinuing PROCARDIA to avoid possible over- or under-digitalization
Carcinogenesis, mutagenesis, impairment of fertility When given to rats prior to mating, nife-
dipine caused reduced fertility at a dose approximately 30 times the maximum recommended hu-
man dose
Pregnancy: Category C Please see full prescribing information with reference to teratogenicity in
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys
ADVERSE REACTIONS: The most common adverse events include dizziness or light-headedness,
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of pa-
tients, transient hypotension in about 5%, palpitation in about 2% and syncope in about 0.5%
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antian-
ginal medication Additionally, the following have been reported: muscle cramps, nervousness,
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shaki-
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus, urticaria, fe-
ver, sweating, chills, and sexual difficulties. Very rarely, introduction of PROCARDIA therapy was
associated with an increase in anginal pain, possibly due to associated hypotension
In addition, more serious adverse events were observed , not readily distinguishable from the nat-
ural history of the disease in these patients. It remains possible, however, that some or many of
these events were drug related Myocardial infarction occurred in about 4% of patients and conges-
tive heart failure or pulmonary edema in about 2%. Ventricular arrhythmias or conduction disturb-
ances each occurred in fewer than 0 5% of patients.
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline phos-
phatase, CPK, LDH, SGOT, and SGPT have been noted, and a single incident of significantly ele-
vated transaminases and alkaline phosphatase was seen in a patient with a history of gall bladder
disease after about eleven months of nifedipine therapy The relationship to PROCARDIA therapy is
uncertain These laboratory abnormalities have rarely been associated with clinical symptoms
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive world
literature
HOW SUPPLIED: Each orange, soft gelatin PROCARDIA CAPSULE contains 10 mg of nifedipine
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069-2600-66), 300 (NDC 0069-
2600-72), and unit dose (10x10) (NDC 0069-2600-41). The capsules should be protected from
light and moisture and stored at controlled room temperature 59° to 77°F ( 15° to 25°C) in the man-,
ufacturer s original container
More detailed professional information available on request © 1982, Pfizer Inc.
LABORATORIES DIVISION
PFIZER INC
24
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Quotes from art unsolicited 1
letter received by Pfizer from an
angina patient.
While this patient's experience
is representative of many
unsolicited comments received,
not all patients will respond to
Procardia nor will they all
respond to the same degre^^
"My daily routine consisted of
sitting in my chair trying to stay alive."
"My doctor switched me to
PROCAR DI A M as soon as it became
available. The change in my condition
is remarkable."
"I shop, cook and can plant
flowers again."
"I have been able to do volunteer
work... and feel needed and useful
once again."
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0 5%).
© 1983, Pfizer Inc.
for the varied faces of angina
* Procardia is indicated for the management of:
1 ) Confirmed vasospastic angina
2) Angina where the clinical presentation suggests a possible
vasospastic component.
3) Chronic stable angina without evidence of vasospasm in
patients who remain symptomatic despite adequate doses of
beta blockers and/or nitrates or who cannot tolerate these
agents. In chronic stable angina (effort-associated angina)
PROCARDIA has been effective in controlled trials of up to
eight weeks' duration in reducing angina frequency and
increasing exercise tolerance, but confirmation of sustained
effectiveness and evaluation of long-term safety in these
patients are incomplete.
PROCARDIA
(NIFEDIPINE}
Capsules 10 mg
Please see PROCARDIA brief summary on adjoining pi
VOL. 81— NUMBER 1— JANUARY 1984
25
JEMPAC REPORT
Political Action and Political Activity
The Medical Society of New Jersey
can look forward to the 1984-1985
session of the legislature with
heightened interest and optimism, thanks in large measure
to our best effort of supporting pro-physician candidates in
the November legislative elections (Table).
Physician response was generous — even enthusiastic — in
the campaign fund raising activities of MSNJ’s political ac-
tion committees, JEMPAC and MedAc. Reflecting the tire-
less efforts of JEMPAC Chairman, William E. Ryan, M.D.,
(Mercer County), the committees together contributed
$66,300 to incumbent legislators and challengers who are
supportive of medicine. In the 120 legislative races, MSNJ
supported 100 candidates of whom 87 won and 13 were
defeated.
Democrats retained control of both the Senate (23-17) and
the Assembly (44-36). The new Senate includes 20 Democrats
and 15 Republicans who received MSNJ support. In the new
TABLE
New Jersey Legislature 1984-1985
District
Senate
Assembly
1
James R. Hurley*
Joseph W. Chinnici— Guy F. Muziani
2
William L. Gormley*
Dolores G. Cooper*— John Edward Kline*
3
Raymond J. Zane*
Martin A. Herman— Thomas A. Pankok*
4
Daniel J. Dalton*
Anthony S. Marsella*— Dennis L. Riley*
5
Walter Rand*
Francis J. Gorman*— Wayne R. Bryant*
6
Lee B. Laskin*
Thomas J. Shusted*— John A. Rocco*
7
Catherine A. Costa*
Barbara Faith Kalik— Thomas P. Foy*
8
H. James Saxton*
Robert J. Meyer*— C. William Haines*
9
Leonard T. Connors, Jr.*
John T. Hendrickson, Jr.*— Jorge A. Rod*
10
John F. Russo*
John Paul Doyle*— Marlene Lynch Ford
11
Frank Pallone, Jr.
Anthony “Doc” Villane*— Joseph A. Palaia*
12
S. Thomas Gagliano*
Marie Sheehan Muhler*— John O. Bennett*
13
Richard Van Wagner*
William E. Flynn*— Jacqueline Walker
14
Francis J. McManimon*
Joseph L. Bocchini*— Joseph D. Patero*
15
Gerald R. Stockman*
John S. Watson*— Gerard S. Naples*
16
John S. Ewing*
Walter J. Kavanaugh*— John (Jack) Penn*
17
John A. Lynch*
David C. Schwartz— Angela L. Perun
18
Peter P. Garibaldi*
Frank M. Pelly*— Thomas H. Paterniti
19
Laurence S. Weiss*
Alan J. Karcher*— George J. Otlowski
20
Raymond J. Lesniak*
Thomas J. Deverin*— Thomas W. Long*
21
C. Louis Bassano*
Chuck Hardwick* — Edward K. Gill*
22
Donald T. DiFrancesco
Bob Franks*— Maureen Ogden*
23
Walter E. Foran*
Richard A. Zimmer— Karl Weidel*
24
Wayne Dumont, Jr.*
Robert E. Littell*— Garabed Haytaian
25
John H. Dorsey*
Arthur Albohn*— Rodney P. Frelinghuysen*
26
Leanna Brown
Dean A. Gallo*— Ralph A. Loveys*
27
Richard J. Codey*
Harry A. McEnroe— Mildred Barry Garvin
28
John P. Caufield*
Michael F. Adubato*— Jimmy Zangari
29
Wynona M. Lipman*
Willie B. Brown* — Eugene H. Thompson*
30
Carmen A. Orechio*
A.J. “Buddy” Fortunato*— Stephen Adubato, Jr.
31
Edward T. O’Connor, Jr.*
Joseph Doria, Jr.*— Joseph Charles, Jr.*
32
Thomas F. Cowan*
Paul Cuprowski*— Anthony Vanieri
33
Christopher J. Jackman*
Robert A. Ranieri — Nicholas J. LaRocca
34
Joseph L. Bubba*
Newton E. Miller*— Gerald Zecker
35
Frank X. Graves, Jr.*
John Girgenti— Vincent Ozzie Pellecchia*
36
Joseph Hirkala*
Robert Hollenbeck— Richard Visotcky
37
Matthew Feldman
Byron Baer— D. Bennett Mazur
38
Paul Contillo
Louis Kosco*— William P. Schuber
39
Gerald Cardinale*
John Markert*— John E. Rooney
40
Garrett W. Hagedorn*
Walter M.D. Kern, Jr.— Nicholas R. Felice*
* = MSNJ Support
26
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Assembly, we supported 24 Democrats and 28 Republicans.
These results tremendously overshadow any of MSNJ's
ipast efforts. For example, JEMPAC was able to contribute
only $18,650 in the 1981 legislative and gubernatorial races;
JEMPAC had 317 members that year. In 1983, JEMPAC’s
1 610 members contributed $27,700 to the legislative races and
MedAc — the fund raising mechanism created specifically for
the legislative elections — contributed $38,600.
Political action of this magnitude comes not a moment too
soon. Last year was MSNJ's most politically active year in
the legislature. We successfully fought the seemingly endless
battle against the combined efforts of administration and the
automobile insurance lobby to create a statutory medical fee
schedule for physician services for auto accident victims. At
the same time, we battled back an extremely well-organized
attempt of the Optometric Association to pass a law per-
mitting optometrists to prescribe drugs. Numerous other
skirmishes Hared up throughout the year: a move by the
physical therapists to establish themselves as freestanding
practitioners, a variety of incursions by nonmedical groups
to gain health insurance reimbursement for their services.
From our lobbying activity we certainly learned who our
friends were in the legislature, and it was time for MSNJ
to show its appreciation for their help by supporting their
campaigns with contributions of $500, $750, and more. One
example stands out: Senator James Bornheimer (D-East
Brunswick), chairman of the Labor, Industry, and Pro-
fessions Committee where many of our battles are fought,
showed a consistent antiphysician bias throughout the
1982-1983 session. In the election we generously supported
Bornheimer’s opponent, Peter P. Garibaldi (R-Cranbury).
Today, Garibaldi is a senator.
The amount of contributions we were able to raise does
not simply put MSNJ “on the map" in the realm of political
action — it reHects medicine’s legitimate growing interest and
involvement in legislation that affects the livelihood of phy-
sicians and the well-being of their patients. Keep up the good
work! Clark Martin
Joseph W. Katz
MSNJ Lobbyists
VOL. 81— NUMBER 1— JANUARY 1984
27
ONLY DALMANE
flurazepam HCI/Roche
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Undiminished efficacy for at
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and refreshed7^
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discontinuation of therapy35,10'12
Caution patients about driving, operating hazardous machinery or drink-
ing alcohol during therapy. Limit dose to 15 mg in elderly or debilitated
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References: 1. Kales J et al: Clin Pharmacol
Ther 12: 691-697, Jul-Aug 1971. 2. Kales A et al:
Clin Pharmacol Ther 18: 356-363, Sep 1975.
3. Kales A et al: Clm Pharmacol Ther 19:
576-583, May 1976 4. Kales A et al: Clin Phar-
macol Ther 32:781-788, Dec 1982. 5. Frost JD Jr,
DeLucchi MR. J Am Genatr Soc 27:541-546, Dec
1979 6. Kales A, Kales JD J Clm Pharmacol
3:140-150, Apr 1983. 7. Monti JM: Methods Find
Exp Clm Pharmacol 3: 303-326, May 1981.
8. Greenblatt DJ et al: Sleep 5 (Suppl 1):S 18-S27,
1982 9. Kales A et al Pharmacology 26:121-137,
1983 10. Greenblatt DJ, Allen MD, Shader R1
Clin Pharmacol Ther 21: 355-361, Mar 1977.
11. Zimmerman AM: Curr Ther Res 13:18-22,
Jan 1971. 12. Amrein R et al: Drugs Exp Clm Res
9(1) :85-99, 1983.
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tions requiring restful sleep. Objective sleep laboratory data
have shown effectiveness for at least 28 consecutive nights of
administration. Since insomnia is often transient and intermit-
tent. prolonged administration is generally not necessary or rec-
ommended. Repealed therapy should only be undertaken with
appropriate patient evaluation.
Contraindicabons: Known hypersensitivity to flurazepam HCI;
pregnancy. Benzodiazepines may cause fetal damage when
administered during pregnancy. Several studies suggest an
increased risk of congenital malformations associated with ben-
zodiazepine use during the first trimester. Warn patients of the
potential risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam Instruct patient to
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following discontinuation. Caution against hazardous occupa-
tions requiring complete mental alertness (e.g. . operating
machinery, driving). Potential impairment of performance of
such activities may occur the day following ingestion. Not rec-
ommended for use in persons under 1 5 years of age. Though
physical and psychological dependence have not been reported
on recommended doses, abrupt discontinuation should be
avoider) with gradual tapering of dosage for those patients on
medication for a prolonged period ol time. Use caution in
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increase dosage.
Precautions: In elderly and debilitated patients, it is recom-
mended that the dosage be limited to 15 mg to reduce risk of
oversedation, dizziness, confusion and/or ataxia. Consider
potential additive effects with other hypnotics or CNS depres-
sants, Employ usual precautions in severely depressed patients,
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Adverse Reactions: Dizziness, drowsiness, lightheadedness,
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tase; and paradoxical reactions, eg., excitement, stimulation
and hyperactivity.
Dosage: Individualize for maximum beneficial effect. Adults:
30 mg usual dosage; 15 mg may suffice in some patients.
Elderly or debilitated patients: 15 mg recommended initially
until response is determined
Supplied: Capsules containing 15 mg or 30 mg flurazepam HCI.
Roche Products Inc.
Manati, Puerto Rico 00701
This Publication
is available in
Microform.
University Microfilms
International
Please send additional information
for
Name
Institution
Street
City
State Zip
300 North Zeeb Road
Dept P R
Ann Arbor, Mi 48106
WHY,
** .:„al students now
Residents and me . ,n organized
have a suong ^ Besiden
medicine. seclion and the Med.cal
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Student Section, ^ ng ptocess ol
ticipate .n m® p municate their con-
the AMA and co leaciership m
cerns. 0e',e'op'"® ne it’s one mote
good reason wny y
0t the AM A.
To Join, state medical
Contact y°u'. ,c°d, vision ot Membe,‘
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(312) 751-6196.
30
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
SPECIAL ARTICLE
AMA Principles of Medical Ethics
The medical profession long has subscribed to a body of ethical
statements developed primarily for the benefit of the patient. As a
member of this profession, a physician must recognize responsibility
not only to patients, but also to society, to other health professionals,
and to self. The following Principles adopted by the American Medical
Association are not laws, but standards of conduct which define the
essentials of honorable behavior for the physician.
Principle I: A physician shall be dedicated to providing compe-
tent medical service with compassion and respect for human
dignity.
Of all the seven Principles, this is the
one that applies specifically to our pro-
fession. In the other six, banker, law-
yer, or architect could be substituted
for physician, and client for patient,
and the statement would be cogent for
that particular profession. But the fact
that only a physician is entrusted with
“laying hands on” the human body
makes the first Principle especially ap-
plicable to medicine. Of all the tasks
allotted to man, none is more privi-
leged than ours in dealing with persons in their raw state,
as it were, and facing the intimate problems of people head
on. This intimacy is so sacred that “unconsented touching
of another person” is enough to warrant an allegation of
battery. Other professions deal with ideas, things, money,
dwellings, movement of objects, communication of thoughts,
means of pleasure, and satisfactions of the soul. Ours deals
directly with people — as someone said, we handle “diseases
of the skin and its contents.” And to this we are dedicated
or set apart, regardless of the specialty chosen or the type
of remuneration accepted. The pathologist is no less con-
siderate of the body he/she dissects than the pediatrician is
of the newborn baby he/she cares for. Whatever our area
of expertise, we are committed to provide capable assistance
and meet the needs of those we serve.
This first Principle guarantees that we do this with a deep
feeling of sharing our patient’s suffering or offering the last
ounce of mercy. In so doing we recognize the inherent worth
of each individual patient — no one should be excluded from
our regard. Our concern should be for all, but particularly
for those who seek help in bearing the burden of sickness
or injury. No problem should be beyond our solving, no
person beyond our care. Even a doctor going through an
illness realizes that one hand cannot wash itself, but a fellow
physician can help make us whole. We can do no less for
any other patient.
The fulfillment of this first Principle is the ultimate in
following the golden rule: “In everything, do unto others as
you would have others do unto you.”
John S. Madara, M.D.
Past President, MSNJ
Principle II: A physician shall deal honestly with patients and
colleagues, and strive to expose those physicians deficient in
character or competence, or who engage in fraud or deception.
I think we logically can break this
Principle down into two separate com-
ponents. The first component is the
obligation of the physician to deal
honestly with patients and colleagues
and second is the obligation of the
physician to expose physicians who are
deficient in character or competence or
who engage in fraud or deception.
I can think of no profession in which
the need for absolute honesty is
greater. Honesty in medicine involves
a careful evaluation of one’s own knowledge and limitations
and an unwillingness to extend one’s efforts beyond those
established boundaries. It requires truth in every area of
professional relationships; in dealing with patients, col-
leagues, hospital staff, patient advocate, and fiscal intermedi-
aries. The physician must be extremely careful in the use of
ancillary medical services that the indication always is the
patient’s need, particularly when those services lead to
financial gain for the physician.
Physicians must accept their responsibility to their pa-
tients, the profession, and the general public to keep the
“medical house” in order by taking action to expose and to
bring appropriate disciplinary action to physicians whose
standards of practice are less than those that have been
outlined above. The concept of honesty in medicine is in
absolute contradiction to the practice of medicine that is
beyond the area of a physician's knowledge, skill, or ex-
pertise or to the obvious dishonesty that must be involved
in fraud or deception in any area of medical practice.
VOL. 81— NUMBER 1— JANUARY 1984
31
We might summarize in the words of the playwright “This
above all else, to thine own self be true then it follows as
the night the day, thou canst be false to any man.”
Physicians who are “impaired” because of mental illness,
physical handicaps, or substance abuse fall into a special
category. These doctors must be exposed as well! The thrust
however, should be to rehabilitate or retire these physicians
who are victims of an illness that they did not seek. Dis-
ciplinary action seldom is needed.
David I. Canavan, M.D.
Medical Director
Impaired Physicians Program, MSNJ
Principle III: A physician shall respect the law and also rec-
ognize a responsibility to seek changes in those requirements
which are contrary to the best interest of the patient.
Principle III was incorporated by the
AMA House of Delegates into the cur-
rent version of the Principles of Medi-
cal Ethics which were adopted in 1980.
The explanatory material, accompany-
ing the revision and published in Cur-
rent Opinions of The Judicial Council of
the AMA — 1982, is helpful in inter-
preting the intent of this particular
statement.
Section 1.02, The Relation of Law
and Ethics of that edition, states, in
part, “Ethical standards of professional conduct and re-
sponsibility may exceed but are never less than, nor contrary
to, those required by law .... Ethical pronouncements of
the Judicial Council and the House of Delegates should not
be so interpreted, construed, or applied as to encourage
conduct which violates a valid law.”
It appears to me that the AMA attempted to resolve the
occasional conflict that professionals of all types have ex-
perienced between law and ethics. It determined that as a
professional society the only course available to it was to
require adherence to and respect of the law, while requesting
and seeking changes that would work toward the protection
of the best interest of the patient.
Principle III, therefore, holds that physicians are to resolve
conflicts between law and ethics in favor of the law. It places
a further burden on the physician, however, by declaring an
affirmative duty to seek changes in any legal requirements
which are contrary to the best interest of the patient.
Vincent A. Maressa, J.D.
Executive Director, MSNJ
Principle IV: A physician shall respect the rights of patients,
of colleagues, and of other health professionals, and shall
safeguard patient confidences within the constraints of the law.
The medical profession’s regard for
patient confidentiality can be traced to
the oath of Hippocrates. The modern
counterpart to the Hippocratic Oath is
Principle IV of the AMA Principles of
Medical Ethics. What do the various
parts of Principle IV mean to me?
First, a patient has a right to assume
that information revealed to a physi-
cian will not be transmitted without
his/her consent. A physician who vio-
lates this trust not only acts unethical-
ly, but also may be held civilly liable for such an un-
authorized disclosure of confidential patient information.
The rationale behind this physician duty to safeguard con-
fidences stems from the necessity that patients seeking medi-
cal attention should feel free to reveal private matters to their
physician without fear of unwarranted disclosures. The
strength and value of the patient-physician relationship must
be based on this safeguard.
What about respect for the rights of colleagues? This ethi-
cal guideline is akin to the golden rule which states “Do unto
others as you would have others do unto you.” In essence,
physicians should try always to be open-minded and respect-
ful of each other and avoid letting personal differences com-
promise patient care. Patient care always comes first and we
should not let our personal convenience interfere with this
necessity. In reality, physicians respect those physician col-
leagues the most who are guided by the patient's welfare and
who dispatch their clinical duties with skill, compassion, and i
the least amount of complaining.
Finally, what does it mean to respect the rights of other
health professionals? To me, this means that physicians;
should accord an appropriate measure of respect and ac-
knowledgement for the other health professionals involved
in caring for their patients. This most obviously includes
members of the nursing staff, as well as technicians, aides,1
orderlies, volunteers, housekeepers, and ambulance person-
nel. They all have much to offer our patients and we could
not function without their cooperation and assistance. They;
deserve to know we appreciate their efforts.
James E. George, M.D., J.D.
Director
Department of Professional Liability, MSNJ!
Principle V: A physician shall continue to study, apply, and
advance scientific knowledge, make relevant information avail- 1
able to patients, colleagues, and the public, obtain consultation,
and use the talents of other health professonals where in-j
dicated.
Principle V actually embodies sev-
eral ideas. First, it reminds the phy- ;
sician that a commitment to the heal-:
ing arts means commitment to a life-
time as a student. For the physician,'
the educational phase never ends; now,
more than ever, medical education is I
a continuum, beginning in under- j
(graduate college, extending through
medical school, residency, and the en- 1
tire career of practice. Medical educa-
Hs tion is integral to medical practice, ut-
terly necessary to its success. It is not an option, not an
individual decision, but an absolute requirement for the
conscientious physician.
Next, Principle V reminds us that a physician may not
keep his/her own counsel and act thereon. Particularly in
the context of contemporary medicine, the physician must
share knowledge with colleagues and, conversely, seek col-
leagues’ knowledge in the patient’s best interests.
Lastly, Principle V reminds us that the physician must
continually teach — teach colleagues, students, patients, fam- j
ily members, and society in general. Only through fulfilling
the role of doctor, which literally means teacher, does the.
physician meet the moral obligation in its broadest sense.
Stanley S. Bergen, Jr., M.D.
President, UMDNJ
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
32
Principle VI: A physician shall, in the provision of appropriate
patient care except in emergencies, be free to choose whom
to serve, with whom to associate, and the environment in which
to provide medical services.
Recently, I was told that Principle
VI of the AMA Principles of Medical
Ethics was a violation of the Civil
Rights Act because the exercise of this
moral right on our part interferes with
the legal rights of others to select a
doctor of their choice. Until that mo-
ment, I had taken this Principle for
granted. I realize now how important
Principle VI is and how fragile our
hold on the exercise of our civil rights.
The law, to some extent, already has
eroded this Principle. We are forced by law to associate
professionally with others whose training is not comparable
to our own.
We certainly find our choice of environment in which to
serve drastically curtailed as regionalization of medical care
removes more and more facilities from the list of those which
are available to us. The coming glut of physicians will limit
these choices by our younger colleagues even more.
Despite these obvious reductions, we have not yet lost our
freedom. To date, the government has not ordered us to
serve any individual nor any group of patients against our
will.
Freedom is seldom lost in a coup. It is milked away bit
by bit and often we are unaware of the teethmarks.
Despite efforts of MSNJ to stop it, Governor Thomas
Kean recently signed into law a bill requiring our carriers
and our hospitals to report to the New Jersey State Board
of Medical Examiners any liability claim settled for more
than $25,000. We fought this bill for 18 months yet most
doctors found out about it only recently when they were
notified of it by their hospitals. The popular no-fault in-
surance bills contain requirements for mandated fee sched-
ules.
We must distinguish carefully between the legitimate
interest of the public in the proper employment of our skills
and the mandated use of those skills. Point of view is impor-
tant. What the public perceives as legitimate interest may be
construed by us as illegitimate intrusion.
Quality audits by our peers in our hospital is legitimate;
reduction or loss of hospital privileges because we fail to
admit patients with high revenue DRGs is illegitimate. The
requirement that we perform free service in hospital clinics
in return for privileges is legitimate; forcfrrg us to accept
indigent persons as private patients in our offices on a capita-
tion basis is illegitimate. Giving our patients sufficient time
to satisfy their fears about their disease is legitimate; requir-
ing that we spend useless time and frighten patients by ex-
plaining every possible far-out, one-in-a-million complica-
tion from a medication or a procedure is illegitimate. Exercis-
ing our options to refer our patients to therapists, chiroprac-
tors, or other paraprofessionals if it is in the best interest
of the patient is legitimate; mandating that we accept those
whose training is not comparable with ours as equals on the
executive committees of our hospital staffs is illegitimate.
If you read carefully all the Principles, you quickly can
see that none can be effective unless Principle VI is preserved.
Its preservation requires a willingness to sacrifice time and
money and a commitment to practice compassionately so
that those who wish to reduce our profession to the level
of a public utility cannot use our own actions against us.
In 1790, John Philpot Curran stated, “The condition upon
which God hath given liberty to man is eternal vigilance
which condition if he breaks, servitude is at once the conse-
quence of his crime and the punishment of his guilt.”
Alexander D. Kovacs, M.D.
President, MSNJ
Principle VII: A physician shall recognize a responsibility to
participate in activities contributing to an improved communi-
That a physician should assume re-
sponsibility for participation in ac-
tivities contributing to an improved
community is a principle of medical
ethics. Nevertheless, only a small per-
centage of physicians participate in
community activities. This most likely
is due to the overwhelming respon-
sibilities associated in caring for pa-
tients, demanding maximum energy,
fulltime and constant training. Also,
the typical medical student was so
steeped in premedical curricula that the student often lacked
perspectives of national and international problems. Preoc-
cupation with the need to pass every science course often
precluded the opportunity to engage in political, social, and
community activities. In general, physicians, medical faculty,
and medical students become carbon copies of each other,
resulting in narrow perspectives due to focusing on the need
to succeed and compete in their field with always more and
more to learn. All of this is totally understandable to those
of us who have struggled through the system.
Furthermore at the time of graduation, the typical medical
student is in heavy financial debt. Thereafter, the debt is
furthered by the financing of a new office, insurance, a car,
and setting up a practice. Young physicians are consumed
by these burdens. In addition, the growing surplus of doctors
has added another anxiety that one might fail.
Nevertheless, the responsibility of physicians to become
involved in community affairs remains. Respect, intelligence,
and potential leadership qualities often are associated with
the profession, and these characterisitics lend themselves
nicely to community participation. Community service can
be extremely variable. School boards, little league football
physicians, library committees, political parties, specific
major projects such as nuclear or antinuclear groups, cancer
societies, volunteer ambulance or volunteer fire departments,
and numerous other organizations are worthy of consider-
ation. Not only can the doctor provide ideas and leadership
to the group but often will meet laypeople of good meaning,
which is a wonderful experience in itself. Even without con-
siously building a practice, these exposures can only help
increase your referral base.
In summary, it is not easy to find a proper perspective
in life, especially if you are a compulsive physician. Follow-
ing one’s responsibility to family, then to profession, and
finally to community one can only bring new meaning to
life. The line between the fortunate and unfortunate is ever
so thin that only by the grace of God have physicians re-
mained above this line. Yet, men so quickly forget from
whence they came. No longer can the medical profession live
like an ostrich. We must become involved with every aspect
of society. It is part of our oath and heritage.
Leon G. Smith, M.D.
St. Michael's Medical Center
VOL. 81— NUMBER 1— JANUARY 1984
33
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INDERAL LA controls blood pressure without the
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INDERAL LA should not be used in the presence of
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34
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
THE
TO COUNTON
Start with 80 mg once daily. . .
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evaluate clinical results to determine if dosage
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n
fa
a
IftlLA
id
RftLLA
1
v •>*
n
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IP
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The appearance of INDERAL LA capsules
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Please see next page for brief summary
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ONCE-DAliy
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(PROPRANOLOL HCI)
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VOL. 81— NUMBER I— JANUARY 1984
35
The one to count on
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BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION SEE PACKAGE CIRCULAR.)
INDERAL* LA BRAND OF propranolol hydrochloride
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DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOQY. INDERAL is a nonselective beta-adrenergic receptor
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INDERAL LA Capsules (80. 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
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capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
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such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
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is usually advantageous and is manifested during exercise by delayed onset of pain and
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significance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the pial vessels of the brain
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For example, in patients with severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
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Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
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hypertensive emergencies.
Angina Pectoris Duo to Coronary Atheroscierosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock, 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE. Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic, action of diqitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible)
Nonaiicrglc Bronchospasm (a.g., chronic bronchitis, omohysamal—
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking therap
prior to major surgery is controversial It should be noted, however, that the impaired ability c
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesi;
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of bets!
receptor agonists and its effects can be reversed by administration of such agents, e g
dobutamme or isoproterenol. However, such patients may be subject to protracted sever!
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported wit.
b6t3 blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent the api
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes) c
acute hypoglycemia in labile insulin-dependent diabgtes In these patients, it may be moil
difficult to adiust the dosage of insulin
THYROTOXICOSIS; Beta blockade may mask certain clinical signs of hyperthyroidisrr
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptom i
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function tests
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have been
reported in which, after propranoloi, the tachycardia was replaced by a severe bradycardi;
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 mol
propranolol.
PRECAUTIONS. General: Propranolol should be used with caution in patients with impaired
hepatic or renal function INDERAL is not indicated for the treatment of hypertensivi
emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patient;'
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal ma)
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart disease;
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS' Patients receiving catecholamine-depleting drugs such as reser
pine should be closely observed if INDERAL is administered The added catecholamine
blocking action may produce an excessive reduction of resting sympathetic nervous activit'
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostatic
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals have
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studies ir
both rats and mice, employing doses up to 150 mg/kg /day, there was no evidence of significan
drug-induced toxicity. There were no drug-related tumorigenic effects at any of the dosage
levels. Reproductive studies in animals did not show any impairment of fertility that was
attributable to the drug.
Pregnancy. Pregnancy Category C. INDERAL has been shown to be embryotoxic ir
animal studies at doses about 10 times greater than the maximum recommended human dose
There are no adequate and well-controlled studies in pregnant women. INDERAL shoulc
be used during pregnancy only if the potential benefit justifies the potential risk to the fetus
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercised wher
INDERAL is administered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and have
rarely required the withdrawal of therapy
Cardiovascular bradycardia; congestive heart failure; intensification of AV block; hypo
tension; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usually of the
Raynaud type.
Central Nervous System, lightheadedness, mental depression manifested by insomnia
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia, visua
disturbances; hallucinations; an acute reversible syndrome characterized by disorientation foi
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, anc
decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhea
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with achinc
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm.
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has beeri
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo
fence, and Peyronie's disease have been reported rarely Oculomucocutaneous reactions
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practolof
have not been associated with propranolol.
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride in a
sustained-release capsule for administration once daily. If patients are switched from INDERAL1
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeutic
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute foij
INDERAL. INDERAL LA has different kinetics and produces lower blood levels Retitration may
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interval i
HYPERTENSION— Dosage must be individualized The usual initial dosage is 80 mg
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may be
increased to 120 mg once daily or higher until adequate blood-pressure control is achieved
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 640
mg may be required The time needed for full hypertensive response to a given dosage is
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL LA
once daily, dosage should be gradually increased at three to seven day intervals until optimurr
response is obtained Although individual patients may respond at any dosage level, the
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value and
safety of dosage exceeding 320 mg per day have not been established.
If treatment is to be discontinued, reduce dosage gradually over a period of a few weeks'
(see WARNINGS).
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL LA
once daily. The usual effective dose range is 160-240 mg once daily. The dosage may be'
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is not,
obtained within four to six weeks after reaching the maximum dose, INDERAL LA therapy
should be discontinued It may be advisable to withdraw the drug gradually over a period of
several weeks.
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age qroup are
too limited to permit adequate directions for use.
•The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratories.
8688/863
AYERST LABORATORIES
New York, N Y. 10017
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advisa-
ble to reinstitute INDERAL therapy and take other measures appropriate for the manage-
ment of unstable angina pectoris Since coronary artery disease may be unrecognized, it
may be prudent to follow the above advice in patients considered at risk of having occult
atherosclerotic heart disease who are given propranolol for other indications
36
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Area Health Education
Center Program
MERWYN A. LANDAY, D.D.S., BENJAMIN L. COHEN, D.O.,
RICHARD C. REYNOLDS, M.D., Camden*
The Area Health Education Center (AHEC) Program is a
decentralized effort to improve health professions education in
southern New Jersey and eventually the health status of the
^population of this region. It is intended to correct the deficit in the
type and numbers of education programs for the health professions in
the region by linking the educational and training programs of the
University of Medicine and Dentistry of New Jersey to community
hospitals, local affiliated educational institutions, and local health
providers in southern New Jersey.
T
he Area Health Education Center
Program in New Jersey consists of
two principal components: the Uni-
versity of Medicine and Dentistry of New Jersey (UMDNJ)
with its cooperating and participating schools, and three
Area Health Education Centers (AHECs). The three AHECs
encompass a region that includes the eight counties of
southern New Jersey (Figure 1).
The UMDNJ schools participating in the AHEC Program
include the New Jersey School of Osteopathic Medicine,
Rutgers Medical School, New Jersey Dental School, and the
School of Health-Related Professions. The New Jersey
School of Osteopathic Medicine developed and secured the
grant and is the management agent for the program. Among
the other institutions to participate in the New Jersey AHEC
Program are 12 affiliated schools, 22 hospitals or major
health care providers, over 30 preceptor offices, and more
than 20 community organizations.
The AHEC Program is a decentralized effort to improve
health professions education, the geographic and specialty
distribution of health manpower, and, eventually, the health
status of the population of southern New Jersey. It is
intended to correct the deficit in the type and numbers of
health professions education programs in the region as well
as to improve the coordination and use of existing resources
by linking the educational and training programs of the
University of Medicine and Dentistry of New Jersey to
community hospitals, local affiliated educational institu-
tions, and local health providers. Using this partnership
approach, the program provides training that specifically
addresses the health personnel needs of particular com-
munities of southern New Jersey.
Southern New Jersey has two related problems in health
status and health manpower. The health status of the eight
counties of southern New Jersey is below the state average,
and there is uneven distribution and some shortages of health
manpower. And, until recently, health professions education
institutions and resources virtually were nonexistent in this
region.
During the first three years (1978 to 1981) of the New
Jersey AHEC Program, the Camden AHEC, an urban area
health education center with an emphasis on Camden City,
was developed in Camden County. This past year, planning
was accomplished for two additional AHECs to cover the
remaining seven counties of southern New Jersey. The new
Garden AHEC covers Gloucester, Salem, and Cumberland
counties in southwestern New Jersey and has urban and rural
components. The new Shore AHEC covers Burlington,
*From UMDNJ, where Dr. Landay is Program Director, UMDNJ-
Area Health Education Center Program, Dr. Cohen is Dean,
UMDNJ-New Jersey School of Osteopathic Medicine, and Dr. Rey-
nolds is Dean, UMDNJ-Rutgers Medical School. Correspondence
may be addressed to Dr. Landay, UMDNJ-AHEC Program, 300
Broadway, Camden, NJ 08103.
VOL. 81— NUMBER 1— JANUARY 1984
37
Figure 1 — The three AHECs encompass a region that includes
the eight counties of southern New Jersey.
Ocean, Atlantic, and Cape May Counties in southeastern
New Jersey and has urban, rural, and geriatric components.
Each of the three AHECs in the program is operated by a
corporate entity independent from UMDNJ. The Camden
AHEC is administered by Camden AHEC, Inc., a not-for-
profit community corporation formed expressly for the
purpose of conducting a regional educational center in
Camden County. The Garden AHEC is administered by the
Bridgeton Hospital Association, which is an independent
corporation that operates Bridgeton Hospital in Cumberland
County. The Shore AHEC is administered by the Atlantic
City Medical Center, which is a hospital with two divisions in
Atlantic County. Both of these are community hospital
corporations which have adopted, as one of their additional
functions, the operation of an area health education center.
Large numbers of students of all types are having signifi-
cant portions of their formal training provided in settings in
southern New Jersey. This includes undergraduate os-
teopathic and allopathic medical students, osteopathic and
allopathic postgraduate students, undergraduate and gradu-
ate dental students, nurse practitioners, nurse midwives,
mental health workers, social workers, and a wide variety of
allied health professionals. In addition, large numbers of
continuing education programs are being conducted in the
previously professionally isolated and underserved southern
New Jersey region to improve the quality and other impor- i
tant features of the health manpower and health services of
the area. These include extensive activities in continuing
education, health education, prevention, nutrition, National
Health Service Corps support, minority recruitment into
health professions, learning resources development, and
health care management.
The intention of the UMDNJ-AHEC Program is to
continue the progress already achieved in Camden County
and to begin to achieve the same results in the remaining
seven counties of southern New Jersey.
THE REGION
Over 1.85 million people live in the eight southern New
Jersey counties which comprise this AHEC Program region.
Seventy-two percent of this population are urban residents
and 28 percent are rural residents.
The major urban concentration in this area, Camden City,
has been ranked as the ninth most distressed city in the
nation on the basis of the percentage of citizens living in
poverty, the percentage of pre-1940 housing, and the rate of j
population decline. Vineland-Bridgeton-Millville, the second
largest metropolitian area in the region, recently was ranked j
as very nearly the worst metropolitian area in the United
States in which to live (267 out of 277 metropolitan areas),
comparing economics, housing, crime, education, health j
care, recreation, transportation, climate, and terrain.1 In i
Atlantic City, the third largest city in the region, 71.3 percent
of Atlantic City public school pupils, a few years ago, were
recipients of Aid to Families with Dependent Children. In
addition, the rural residents of southern New Jersey have
high rates of unemployment and high numbers of families
below the poverty level because of the troubled farm in-
dustry.
In 1979, two general indices of health status, the Standard- !
ized Mortality Ratio (SMR) and the Years of Life Lost Index
(YLL), revealed that the health status of the residents of
southern New Jersey is poor. Among the 200 health service j
areas (HSAs) across the country, southern New Jersey
ranked worse than 156 others in general health status.2 Parts
of the area experience generally higher than average morbidi-
ty and mortality rates, high infant mortality, and other
specific indicators of poor health status. In addition, poor ‘
access to health care exists in the region due to economic, ;
cultural, linguistic, geographic, and transportation barriers.
For portions of the population of the region, access largely is
limited to crisis care, with little preventive medicine, early
detection of disease, or health education.
Of the eight-county southern New Jersey areas, five coun-
ties had portions of their region classified as primary care
Health Manpower Shortage Areas (HMSA) or Medically
Underserved Areas (MUA). All of the 20 census tracts in the
city of Camden have been designated as primary care
HMSAs. In addition, areas of southern New Jersey have
only 1 primary care physician per 3,500 to 5,000 population,
and some areas have even less than 1 physician per 5,000
population.3 The New Jersey Department of Higher Educa-
tion projected the need for an increase of 25.3 percent or 680
38
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
physicians by 1985 for the southern New Jersey area,4 if
foreign medical graduates are restricted. In addition, there is
a need for other health care professions manpower in certain
parts of the region such as nurse practitioners, dentists,
nurses, and allied health workers of many types.
Finally, until the arrival in 1978 of the New Jersey AHEC
Program and the recent beginning of the development of a
southern campus of UMDNJ in Camden County, there was
a virtual absence of health professions educational programs
in southern New Jersey.
GOALS
The goals of the UMDNJ-AHEC Program are to plan,
develop, and operate area health education centers in the
eight counties of southern New Jersey in order to: improve
the supply, distribution, quality, utilization, and efficiency of
health manpower in the health service delivery system and
ultimately the health of the residents; to accomplish this
through the extension and regionalization of educational
responsibilities of currently existing health professions
schools.
ORGANIZATIONAL STRUCTURE
The University of Medicine and Dentistry of New Jersey is
the state-supported system for health professions education
for New Jersey. It is a multicampus institution for educating
health personnel with more than 2,000 students enrolled in
doctor of medicine, doctor of osteopathy, doctor of dental
medicine, doctoral and master of science programs, and
many hundreds more in allied health programs, with cam-
puses in Newark, Piscataway, and a newly developing cam-
pus in Camden. UMDNJ serves as the recipient of the
AHEC Program cooperative agreement. One of its compo-
nents, the UMDNJ-New Jersey School of Osteopathic Medi-
cine, is the cooperating school, as well as the management
agent for the program. The organizational structure of the
program is illustrated in Figure 2 and is modeled on federal
recommendations to carry out the mandate of the AHEC
Program legislation designed to assure a significant non-
university voice in AHEC program functioning.
The UMDNJ-New Jersey Dental School and the
UMDNJ-School of Health-Related Professions both are
participating schools in the program. The UMDNJ-Rutgers
Medical School, which in the past was involved only for the
purchase of services for which it had unique resources, in-
tends to increase its role in the program as the Garden and
Shore AHECs become operational.
ACCOMPLISHMENTS IN MEETING FEDERAL AHEC
REQUIREMENTS AND PROGRESS TO DATE
The UMDNJ-New Jersey AHEC Program has met all of
the requirements in Section 781 of Public Law 94-484 and
associated Rules and Regulations, and the Program Guide
for Area Health Education Center Programs. Meeting these
requirements and regulations was considered to be the
minimum acceptable performance for this program.
The real accomplishments and richness in the UMDNJ-
AHEC Program are in the many new educational programs
and activities that go beyond the basic 781 requirements. For
example, 12.8 percent, rather than 10 percent, of the clinical
education of the New Jersey School of Osteopathic Medicine
now occurs in AHEC settings. Although only two other
health professions schools other than the cooperating school
are required to participate in an AHEC program, nine
schools now rotate students into the Camden AHEC alone
Figure 2 — The organizational structure of the UMDNJ-AHEC
Program.
for clinical experiences as a result of the New Jersey AHEC
Program. Although only 75 percent of the funds awarded to
the program must pass to the centers, 8 1 percent in fiscal year
1983 and 85 percent in fiscal year 1984 will go to the centers.
Although either a nurse practitioner or physician’s assistant
program is required, new clinical training programs for
nurse-midwives, nurse-practitioners, and physician’s assis-
tants have been brought into the region. A new family
practice residency has been started which had over 20
applicants for seven positions this past year. Innovative
continuing education programs have been offered in content
areas relating to practice in underserved areas. Nutrition
education has been newly provided to the region. Health
professionals now receive skills training in health education
important to the promotion of health in the area. National
Health Service Corps members receive assistance while locat-
ing and practicing in the area, as well as a potential faculty
appointment at UMDNJ-NJSOM and UMDNJ-RMS.
Thousands of minority and disadvantaged high school stu-
dents have been exposed to health career opportunities. The
Center Board of Directors and Center and Program Ad-
visory Committees have involved extraordinarily large num-
bers of health professionals and broad community constit-
uencies in developing educational programs needed in this
region, and providing many of the resources for their
support.
In this past year, 93 undergraduate osteopathic medical
students spent a total of 11,928 student hours in AHEC
settings and institutions in the region. The AHEC Program
provided supporting resources for 105 existing and new
primary care residents and rotating interns. As part of the
developing Rutgers Medical School of Camden, 70 al-
lopathic undergraduate medical students spent rotations in
southern New Jersey, and 12 Fifth Pathway students spent a
full year in the Camden inner city. All 86 dental students
from the northern part of the state rotated through the
AHEC region for a total of 1,204 student hours of instruc-
tion in AHEC settings in the region. Extensive rotations were
provided in nursing, allied health, and social work education.
These included nurse midwifery students full time for 15-
week rotations, nurse practitioner students for 18-week
rotations, physician’s assistant students for 4 weeks full time,
social work graduate students for three days a week for a
year, and dietary technician students for 60 hours each.
Other allied health rotations occurred in mental health,
VOL. 81— NUMBER 1— JANUARY 1984
39
physical therapy, and dental hygiene, for a total of approx-
imately 6,000 student hours of clinical experience in the
AH EC region. Over 200 students from various disciplines
participated in formal educational programs in health care
management. In nutrition education, 85 students were in-
volved in direct instruction and clinical experiences in the
region. Over 50 minority and disadvantaged students were
involved in extensive health careers development programs
for over 2,500 student hours of educational experience. In
continuing and other education in the past two years, over 75
courses have been conducted in Camden with 2,463 partici-
pants, for over 9,000 participant hours. In addition, over
2,000 students in various high schools throughout the region
were involved in health careers awareness programs.
As a result of the AHEC Program, a number of other
significant accomplishments have occurred. Nursing educa-
tion at the graduate level has increased considerably in the
region with the development of a nurse-midwifery, a nurse
practitioner, and a continuing education effort. The cooper-
ating medical school now accepts the AHEC rotation into
underserved areas as part of their standard curriculum. A
large number of clinical rotations have started in the region
which are expected to lead to a more favorable distribution
of health personnel in southern New Jersey. Partnerships
have been established between many health professions
training institutions and local health providers and educa-
tional institutions in the region. The AHEC Program has
provided the link between the health sciences centers in the
northern and middle parts of the state and the underserved
areas of southern New Jersey. An enhanced professional
environment has begun to develop for health professionals in
southern New Jersey which should make this area a more
attractive location in which to practice. The University has
begun to help increase the skills of practitioners and adminis-
trators in health care delivery with its health care man-
agement training. And, most importantly, the AHEC Pro-
gram through its broad extension of educational programs
and the University presence into this previously neglected
area has begun to address the health manpower needs of the
area.
SCOPE OF FUTURE WORK
The next two years will move the New Jersey AHEC
Program further towards a three-center program. In 1983,
the Camden AHEC entered its fifth year and continues to
function at a fully operational level through increased local
support. The Garden and Shore AHECs will enter their
developmental years and continue to form the necessary
linkages and partnerships, as well as design the educational
programs needed in this region. In addition, during this next
year, continuing education and the start of student rotations
in a number of disciplines will begin in the Garden and Shore
AHECs. In 1984, the Garden and Shore AHECs will enter
their operational years and conduct the wide variety of
educational programs developed for their regions.
During 1983, formal educational programs conducted in
the AHEC region include 20 disciplinary areas and over 900
students. Three hundred forty-eight students are from os-
teopathic and allopathic undergraduate and postgraduate
medical education, 89 students from dental education, 54
students from allied health, and 85 students from nutrition
education. In addition, social work education involves 60
students; health care management, 200 students; and health
education, 35 students. Also, a total of 10,812 participants
are involved in almost 30,000 hours of continuing education
programs in the fields of medicine, dentistry, nursing, allied
health, health care management, and multidisciplinary top-
ics.
During this next year, the New Jersey AHEC Program will
place emphasis on the development of the Garden and Shore
AHECs. Both centers will continue the formation of partner-
ships with potential participating institutions as well as
piloting new rotations for students needed in the region. The
development of a geriatric emphasis for the Shore AHEC
will be continued so that appropriate student experiences are
planned and readied for implementation. Emphasis on nurs-
ing education is planned throughout the region with in-
creased activity in innovative education which attempts to
keep nurses in the work force and increase their job satisfac-
tion. Efforts also will be made to develop the region as a
model for NHSC placements and innovative extensions of
learning resources into this region through an existing con-
sortium will be pursued.
The extension into the remaining seven counties of south-
ern New Jersey during these next three years, besides ad-
dressing the needs of the population of this area, will increase
the number of students enrolled in AH EC-supported ac-
tivities and enhance student experiences by providing rota-
tions in a variety of sites and an opportunity to work with
urban, rural, migrant, and geriatric patient populations.
With the types and numbers of educational programs
projected, UMDNJ will continue to develop an increased
presence and responsibility throughout the region and con-
tinue to bring about the necessary interinstitutional change
and resources needed to address the health education and
health manpower needs of southern New Jersey.
PROJECTED OUTCOMES
The UMDNJ-New Jersey AHEC Program will achieve a
number of important organizational, educational, and com-
munity outcomes in the region.
Organizational outcomes include the following;
1. Three AHEC regional education centers will have been
developed.
2. The University of Medicine and Dentistry of New
Jersey will have another structure to provide educational
programs to the complete southern New Jersey region.
3. Multiple linkages and partnerships in educational pro-
grams will have developed between components of UMDNJ
and community hospitals, local affiliated educational institu-
tions, and local health care providers.
4. The numbers of primary care health professions train-
ing programs and students will have been increased.
5. Significant institutional change will occur in the tradi-
tional pattern of health professions education.
Educational outcomes include the following;
1. UMDNJ will have regionalized its medical, dental, and
allied health education programs into the southern New
Jersey area.
2. The deficiency in health professions educational pro- i
grams in southern New Jersey will have been relieved.
3. Coordination of the education and training of medical,
dental, nursing, social work, mental health, and allied health
workers in primary care will have increased.
4. Coordination and increase of the quality of continuing
education will have occurred throughout the region.
5. Coordination and integration of UMDNJ health pro-
fessions education programs with local health professions
education programs will have increased.
6. Important educational experiences in primary health
40
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
care with urban, rural, and geriatric populations will have
been added to the educational programs of UMDNJ and
affiliated schools.
7. Highly needed academic programs will have been de-
veloped in a most cost-effective manner through the com-
bination of resources in multiinstitutional partnerships.
Community outcomes include the following:
1. Professional isolation will be reduced and an im-
proved professional environment will have been developed in
underserved areas of southern New Jersey.
2. Retention of students and residents trained in south-
ern New Jersey will be improved.
3. Geographic distribution of primary care health pro-
fessionals will be improved.
4. Needed health professions educational programs will
have been extended into the underserved communities in the
region.
5. The supply of primary care physicians and other types
of health manpower needed in the underserved areas of the
region will have increased.
6. The quality of the health professionals practicing in
underserved areas will be improved.
7. Access to primary health care services for residents in
the underserved areas of southern New Jersey will increase.
8. There will be larger numbers of representatives of
minorities and disadvantaged populations in the health
professions of the region.
9. Health care practices in the region will be improved.
10. The health status of the residents of southern New
Jersey ultimately will improve.
SPECIAL FEATURES OF THE PROGRAM
The AHEC Program in New Jersey has several special
features:
1. Collaboration between Osteopathic and Allopathic Phy-
sicians. The development of a multiinstitutional partnership
to establish an AHEC program in southern New Jersey
required a concerted effort of the osteopathic and allopathic
professions working together to address the health education
and health care needs in the community. This represents a
significant collaborative effort between these two segments
of the medical profession. Although other AHEC programs
have osteopathic schools as participants, this is the only
program in which an osteopathic medical school is the
cooperating school and the management agent working in
partnership with a large number of allopathic institutions.
This is increasing the cooperation between these two seg-
ments of the medical profession in this region.
2. Pioneering Efforts in Statewide Health Professions
Education. New Jersey is one of the leading states that is
developing a statewide university of the health professions
with multiple campuses and regionalized education responsi-
bility. The New Jersey AHEC Program provides the final
link to this regionalized statewide approach by providing
health professions education into the remaining educational-
ly deficient southern part of the state.
3. Pioneering Efforts in Urban Area Health Education
Centers. The UMDNJ-AHEC Program was one of the
earliest urban AHECs when it was established in 1978. In the
city of Camden it dealt with perhaps the most depressed and
deficient urban area addressed by an AHEC. This extensive
experience will be invaluable for use for the urban residents
who represent 72 percent of the population in the eight
counties of southern Jersey. In addition, this experience is
available for use in other urban areas of New Jersey which,
with 13 standard metropolitan statistical areas, is the most
urbanized state in the United States.
4. Pioneering Efforts in Health Care Management. This
AHEC program is unique, with its high emphasis on increas-
ing the skills in management in the health care delivery
system of the state. This is especially important in a state that
has placed its whole hospital industry on a prospective
reimbursement system to contain health care costs and is in
critical need of skilled management to accomplish this
change. In addition, this training has significant implications
in cost containment and is providing students with the
practice management skills to locate in underserved areas, as
well as the patient management skills to treat the special
needs of the populations found in these underserved areas.
5. Pioneering Affiliations with the National Health Service
Corps. Working with the regional office, four NHSC place-
ments were assigned on July 11, 1982, in Camden AHEC
Provider settings and will receive appointments to the
UMDNJ-NJSOM faculty. These assignees will meet their
Corps service delivery requirements, as well as have the
professional stimulation and permanent appeal, of an educa-
tional role. Once this model is evaluated, the regional office
would like to develop additional dual service-educational
placements throughout southern New Jersey.
6. Potential in Geriatrics-Gerontology Education and Ser-
vice. The extraordinarily high geriatric populations in the
counties of south Jersey, especially along the Atlantic shore,
present both a need and an opportunity for New Jersey. This
is a severely underserved population. The potential exists to
make the Shore AHEC the focus for geriatric-gerontology
rotations and training for the UMDNJ system and to secure
external funding sources for support.
7. Extraordinary Cost Effectiveness of the Program. The
benefits and effectiveness of the UMDNJ-AHEC Program
are extremely high in comparison to the costs of the pro-
gram. Larger numbers of students and populations and
larger areas are being impacted by the program than
projected in the original UMDNJ proposal to the federal
government and at funding levels which never have reached
near the levels of those requested in the original proposal. In
addition, innovative programming is planned to allow the
developing Garden and Shore AHECs to meet all Section
781 requirements without high costs. The intent is to provide
high quality, noncostly models of area health educations
centers in the Garden and Shore regions.
CONCLUSION
The UMDNJ-AHEC Program is critical to the improve-
ment of the health manpower and health status of the
residents of southern New Jersey. With its decentralized and
regionalized approach to the problem, extending and linking
currently existing health professions schools to the local
community, it is providing a highly cost-effective approach
to the health personnel needs of southern New Jersey.
REFERENCES
1. Boyer R, Savageau D: Places Related Almanac. New York,
NY, Rand McNally Co., 1981.
2. Southern New Jersey Health Systems Agency: Health Systems
Plan, 1979-1984, pp 31.
3. Southern New Jersey Health Systems Agency: Health Systems
Plan, 1979-1984, pp 63.
4. New Jersey Department of Higher Education: Graduate Medi-
cal Education Master Plan. Physician Need Projection by Specialty
and Geographic Location for New Jersey. Office of Research and
Manpower, 1981.
VOL. 81— NUMBER I— JANUARY 1984
41
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42
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CASE REPORTS
Infantile Embryonal
Carcinoma in Children
PHILIP S. AFFUSO, M.D., and
A. OLUSEGUN FAYEMI, M.D., Teaneck*
We report two children with infantile embryonal carcinoma of the
testis presenting as painless testicular enlargement in one case and a
clinical picture indistinguishable from a hydrocele in the other. The
patients underwent orchiectomy without lymph node dissection or
adjuvant chemotherapy.
Primary testicular neoplasms are rare
in infancy and childhood. Two to 5
percent of all testicular tumors oc-
cur in children and the majority of these make their ap-
pearance before the age of two years.1 Approximately 35 new
cases are diagnosed annually throughout the United States.2
This report concerns the occurrence of primary malignant
testicular neoplasms in two children. The lesions were treated
by surgery alone with a followup period of one-and-a-half to
two years, respectively.
CASE REPORT 1
A two-year-old boy was brought to the emergency room
because of painful enlargement of the right scrotum. Two
months prior to admission he was diagnosed as having a
hydrocele and elective hydrocelectomy had been planned.
Physical examination revealed the right scrotum to be
diffusely enlarged and tender. Because of the possibility of an
incarcerated hernia, emergency operation was performed
through an inguinal incision. At surgery, the right testis was
found to be completely replaced by tumor and right radical
orchiectomy was performed.
The testis, which measured 4.5 x 3 x 3 cm, showed a
smooth and glistening tunica albuginea. Almost the entire
testicular substance was replaced by a yellow-gray tumor
showing focal hemorrhage, necrosis, and, in areas, a mucoid
appearance.
Microscopically, malignant epithelial cells were arranged
in glandular forms with prominent papillary pattern (Figure
1). The lumen of some contained lightly eosinphilic
amorphous material. The tumor cells usually were hyper-
chromatic, some showing prominent vacuolated cytoplasm.
The postoperative course was uneventful. He subsequently
was referred to Memorial Sloan Kettering Medical Center
where detailed investigation revealed no evidence of
metastases, hence no further treatment was administered.
Two years following surgery, the patient is alive and well.
Careful followup has failed to reveal any evidence of recur-
rence.
CASE REPORT 2
An 18-month-old child was evaluated for a two- week
history of painless swelling of the right scrotum. Physical
examination revealed that the right testis was diffusely
enlarged, nontender, and soft. Transillumination was pos-
sible and, therefore, the diagnosis of a hydrocele was enter-
tained although a testicular neoplasm could not be excluded.
The preoperative chest roentgenogram, beta unit of human
chorionic gonadotropin (HCG) and alpha fetoprotein were
all negative.
Exploration through an inguinal incision was performed.
The testis was found to be enlarged and replaced by a
gelatinous-like tumor. A radical orchiectomy was performed.
The testis measured 3.2 cm in maximum dimension,
showed a smooth tunica albuginea, and, on section, revealed
replacement of testicular parenchyma by a soft light-pinkish
*From Holy Name Hospital where Dr. Affuso is Attending
Urologist and Dr. Fayemi is Attending Pathologist. Correspondence
may be addressed to Dr. Fayemi, Holy Name Hospital, Department
of Pathology, Teaneck, NJ 07666.
VOL. 81— NUMBER 1— JANUARY 1984
43
Figure 1 — Testicular tumor showing distinct and prominent
papillary pattern. The glandular lumens contain eosinophilic
material. Many cells show vacuolated cytoplasm (H&E, xlOO).
Figure 2 — Embryonal carcinoma dispersed in loosely woven
masses and forming tubular spaces. Cytoplasmic vacuolation
commonly is observed (H&E, xlOO).
Figure 3 — Testicular tumor showing irregular cystic cavities and
a Schiller-Duval body (H&E, xlOO).
tumor with mucoid appearance. The surrounding testicular
parenchyma was compressed and atrophic.
Microscopically, the tumor was composed of undifferen-
tiated vacuolated cells disposed in loosely woven masses and
forming irregular tubular spaces with small cystic cavities
(Figure 2). Present in several areas were Schiller-Duval
bodies consisting of a central capillary surrounded by a
mantle of cuboidal cells projecting into a capsule lined by
similar cells (Figure 3).
The postoperative course was uneventful. Although he was
referred to Memorial Sloan Kettering Medical Center for
further evaluation, no further treatment was administered
Eighteen months postoperatively, the patient is alive and well
without evidence of recurrence.
DISCUSSION
Childhood testicular tumors are so rare that only about 35
new cases are being diagnosed annually in the United States,
Because of the infrequent occurrence of neoplasms, scrotal
enlargement in childhood usually is assumed to be due to a
hydrocele. The diagnosis of a testicular tumor may be missed
on initial physical examination, as was shown in the two
cases reported in this paper.
About 80 percent of testicular tumors in infancy and
childhood are derived from germ cells; three histological
patterns of these tumors are recognized: embryonal
carcinoma, teratoma, and seminoma.3 While seminomas are
extremely rare, they usually occur beyond the age of ten
whereas embryonal carcinomas and teratomas occur most
commonly during the first three years of life.
Numerous synonyms of embryonal carcinoma abound,
based partly on the histologic morphology and partly on
suggested pathogenetic mechanisms: infantile embryonal
carcinoma,4 juvenile embryonal carcinoma,3 yolk sac tumor,
and endodermal sinus tumor.6 Adult-type embryonal
carcinoma, a distinctive histologic and clinical entity, also
may occur in childhood. Unlike its infantile counterpart, this
tumor has a more aggressive behavior and shows a proclivity
to retroperitoneal lymph node metastasis.
Much of the confusion regarding the treatment of em-
bryonal carcinoma stems from the failure of some authors to
make a morphologic distinction of the infantile form from
the adult type.710 The occurrence of the adult-type lesion
calls for orchiectomy combined with retroperitoneal lymph
node dissection with or without chemotherapy, whereas with
the relatively less malignant course of the infantile em-
bryonal carcinoma, radical orchiectomy with high ligation of
the cord often suffices.11
It has been suggested that such children be followed
closely by clinical examination, monthly chest x-rays, and
determination of serum tumor markers (alpha fetoprotein
and beta subunit of HCG) in the first year following surgery.
REFERENCES
1. Young PG, Mount BM, Foote FW, Whitemore WF: Em-
bryonal adenocarcinoma in the prepubertal testis. A clinico-
pathological study of 18 cases. Cancer 26:1065, 1970.
2. Excelby PR: Personal communication.
3. Mostofi FR, Price EB: Tumors of the male genital system.
Atlas Tumor Pathology, Armed Forces Institute of Pathology,
Washington, DC, 1973.
4. Mostofi FR: Infantile testicular tumors. Bull NY Acad Med
28:684, 1952.
5. Abal MR, Holtz F: Testicular neoplasms in infants and
children I. Tumors of germ cell origin. Cancer 16:965, 1963.
6. Teilum G: Classification of endodermal sinus tumor
(mesoblastoma istellium) and so-called “embryonal carcinoma” of
the ovary. Acta Pathol Microbiol Scand 64:407, 1965.
7. Puri P, Guiney EJ: Testicular neoplasms in children. Urology
9:624, 1977.
8. Drago JR, Nelson RP, Palmer JM: Childhood embryonal
carcinoma of testes. Urology 12:499, 1978.
9. Smith JP: Testicular tumors in infants and children. Urology
2:353, 1973.
10. Hopkins TB, Jaffe N, Colodny A, Cassady JR, Filler RM:
The management of testicular tumors in children. J Urol 120:96,
1978.
11. Exelby PR: Testicular cancer in children. Cancer 45:1803,
1980.
44
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Peroral Esophageal Endoprosthesis
for the Management of Incurable
Esophageal Carcinoma
VI. NURI KALKAY, M.D., BERNARD PANCER, M.D.,
VRNOLD DERMAN, M.D., Holmdel*
A 67-year-old woman presented with progressive dysphagia,
weight loss, marked sialorrhea, and recurrent upper respiratory
tract infections secondary to a malignant, nonresec table
esophageal carcinoma. A quick, immediately effective palliation
was achieved, in two sessions, by serial dilatations of the
malignant stricture with Eder-Puestow bougies and placement of
a peroral esophogeal endoprosthesis. General principles of
peroral esophageal endoprosthesis are discussed and compared
with other modalities of palliation.
Carcinoma of the esophagus has a
poor prognosis no matter what
form of treatment is attempted.1'6
By the time the disease becomes symptomatic and the patient
seeks medical advice, most of the cases already are in-
operable or nonresec table. Under these circumstances, pa-
tients gradually become desperate and will do almost any-
thing in order to be able to eat again.
The primary goal of therapy, for these patients, is pallia-
tion.3'6 The most humane form of palliation is to enable
them, with minimal risk, to take their food and continue to
eat during their remaining days. Surgical palliative interven-
tions carry unacceptable risks for a palliative procedure, 16
and a feeding gastrostomy leaves the patient with a miserable
existence. Thus, peroral esophageal endoprosthesis, a simple,
quick, effective and low-risk procedure, becomes the treat-
ment of choice in nonresectable obstructing esophageal
carcinoma.3'9, 11
The purpose of this paper is to present an illustrative case
of an obstructing esophageal carcinoma and to share our
experience regarding peroral insertion of esophageal pros-
thesis for palliation purposes.
CASE REPORT
A 67-year-old black female was admitted to the hospital
because of progressive dysphagia, marked weight loss, and
recurrent upper respiratory tract infections. Solid food dys-
phagia started six months prior to admission and
progressively became worse, so that she was not even able to
swallow her saliva. She lost approximately 30 pounds during
this time.
She had a past history of moderate, daily alcohol con-
sumption, heavy smoking, and hypertension.
Physical examination revealed an emaciated black female
in acute respiratory distress, with marked sialorrhea, con-
stant cough, and wheezing. Blood pressure was 200/110;
pulse was 1 16 and regular, and temperature was 100.6. There
was no peripheral lymphadenopathy. The trachea was in the
midline. The lung fields were clear to percussion, but re-
*From Bayshore Community Hospital where Dr. Kalkay is Chief of
Medicine, Dr. Pancer is Chief of Radiology, and Dr. Derman is
Attending, Department of Radiology. Correspondence may be
addressed to Dr. Kalkay, Bayshore Community Hospital, Holmdel,
NJ 07733.
VOL. 81— NUMBER 1— JANUARY 1984
45
Figure 1 — Carcinoma of the esophagus. A large, irregular,
circumferential lesion with shelfing and marked luminal narrow-
ing is demonstrated in the thoracic esophagus.
Figure 2— Barium swallow, following the procedure, demon-
strates proper placement of esophageal endoprosthesis without
leakage or perforation.
vealed diffuse rhonchi and wheezing to auscultation. The
liver and spleen were not enlarged.
An x-ray of the chest was normal. A barium swallow
revealed a large, constricting, irregular thoracic esophageal
lesion measuring 10 cm in length (Figure 1). After pre-
medication with meperidine 50 mg IV, atropine 0.5 mg IM,
and diazepam 5 mg IV, an Olympus GIF-P2 gastroscope was
passed under direct vision to the level of the stricture. The
lumen was only 5 to 6 mm in diameter. Under fluoroscopic
control, a guide wire was passed through the stricture and
positioned in the stomach, and serial dilatations were carried
out with the Eder-Puestow dilators. In spite of considerable
mechanical resistance, dilatation was continued to a 35 F
size. This immediately was followed by esophagogas-
troduodenoscopv which demonstrated a circumferential ir-
regular elongated 12 cm lesion. The esophagogastric junc-
tion, stomach, and duodenum were normal. Biopsy, brush
cytology, and washings were done and all were positive for
squamous cell carcinoma. After 24 hours rest, the dilatation
to a 50 F size was carried out and a Key-Med Atkinson
esophageal prosthesis was placed with ease, perorally, under
direct endoscopic view and with the aid of a pusher tube.
Repeat barium swallow, performed immediately after the'
procedure, demonstrated that the prosthesis was in perfect
position, without leakage or perforation (Figure 2). The
patient was placed on a blenderized diet. No dysphagia
occurred. Washing down with water was occasionally re-
quired. The patient was particularly pleased with the return
of normal swallowing.
Further investigation included liver/spleen scan and bone
scans that were normal. CT scan of the chest demonstrated
local lymph node involvement.
The patient’s clinical condition improved rapidly; she
gained weight and a few days later was referred for radio-
therapy as an outpatient.
DISCUSSION
A definite cure of esophageal cancer lies only in its
prevention and early detection,1,4'6'7 both of which, un-
fortunately, are very rarely possible. By the time the patient
seeks medical advice, the disease already is widespread and
nonresectable.1'6 Therefore, in this situation, palliation re-
46
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
;igure 3— The pusher tube and Key-Med Atkinson en-
loprosthesis are assembled on an Olympus GIF-P2
(astroscope ready for insertion.
nains the only achievable goal.4,6 Although surgery frequent-
ly is used for this purpose, it rarely is a successful option in
he management of terminal esophageal cancer.4'6 The suc-
ess of surgical palliation will depend on the location and the
ize of the esophageal cancer.4,6,8,12,13 Lower esophageal
esions offer the best chance for surgical palliation. The
ilassification and staging of esophageal cancers have been
low to evolve. CT scanning can contribute significantly to
he staging and selection of the best potential surgical
:andidates.4, 6,8,12,13 In general, one may state that the smaller
he lesion, the better the chance of survival. In one series, 66
percent of the patients with lesions smaller than 5 cm
survived more than one year.14
Radiotherapy temporarily may alleviate dysphagia, but an
unobstructed esophageal lumen may be difficult to maintain
(with radiotherapy alone.4,7 Furthermore, because of initial
edema secondary to radiotherapy, complete obstruction of
esophageal lumen may be unavoidable. Therefore, no patient
with carcinoma of the esophagus should have radiotherapy
without adequate dilatation and/or insertion of esophageal
prosthesis.3,4,6
Conventional chemotherapeutic agents have limited val-
ue,1,3 but newer investigational drugs appear to be substan-
tially more effective.5 Trials of endoscopic palliative therapy
with laser, for obstructing esophageal carcinomas, have been
tried successfully but they are in an experimental stage.13
Feeding gastrostomy leaves the patient with a miserable
existence for the rest of his or her life. Marked sialorrhea,
with associated aspiration, continues unabated.
DILATATION AND ESOPHAGEAL PROSTHESIS
Thus, it seems clear that the best palliative method, which
is the easiest, safest, and quickest for the nonresectable
carcinoma of the esophagus, is peroral dilatation and inser-
tion of an esophageal prosthesis,4,6,9,11 with or without
radiotherapy. Pull-through esophageal endoprosthesis re-
quires another surgical intervention and carries a significant
morbidity and mortality for a palliative procedure.15 There-
fore, it should be replaced by push-through peroral
esophageal endoprosthesis.
The peroral esophageal endoprosthesis can be placed
anywhere in the esophagus except above and in the im-
mediate vicinity of the crycopharyngeal muscle, because of
foreign body sensation and dangerous pressure effect on the
adjacent organs.3,6 It provides an effective means of pallia-
tion in all malignant esophageal obstructions, due to
esophageal carcinomas and to gastric and pulmonary
carcinomas involving the esophagus.3,4,6,8,9,11,12 Esophageal
endoprosthesis especially is indicated in bronchoesophageal
fistulae.9,12 It is contraindicted in benign esophageal stric-
tures.6
Before any attempt is made to insert the esophageal
prosthesis, the location, configuration, and length of the
tumor must be determined accurately and a tissue diagnosis
must be obtained. Barium swallow, especially endoscopic
measurements and biopsy, washings, and brush cytology are
most important for diagnosis and evaluation. Not only the
length of the tumor, but also the distance between the teeth
and proximal end (shelf) of the tumor and the proximity of
the distal end of the tumor to the cardia should be recorded
carefully. These measurements are extremely important in
tailoring a prosthetic device or selecting a commercially
available one to fit the patient’s particular need. Precise
measurements also are mandatory for proper placement of
the device within the esophagus.
According to the method precisely described by Palmer
and Boyce,17 a prosthetic device can be tailored easily to the
patient’s need, from inexpensive polyvinyl tubing. At the
same time, a pusher tube measuring 45 cm in length can be
prepared. The distance between the teeth and the proximal
shelf of the tumor should be marked on the distal end of the
pusher tube. This mark will indicate how far the prosthesis
should be pushed into the esophagus. The length of the
prosthesis should be 2 to 3 cm longer than the length of the
tumor so that tumor overgrowth will not cause obstruction
of the prosthesis.
The malignant stricture should be dilated to at least 45 F
luminal diameter before a prosthesis is inserted. The pace
and intervals between dilatations depend on the patient’s
tolerance, the distensibility of malignant stricture, and the
development of complications such as perforation, copious
bleeding, or aspiration pneumonia.
“Before any attempt is made to
insert the esophageal prosthesis,
the location, configuration, and
length of the tumor must be de-
termined accurately and a tissue
diagnosis must be obtained.”
If there is no marked tortuosity in the malignant stricture
or bronchoesophageal fistula, larger diameter dilatations (35
F and over) may be carried out without a guide wire and with
Hurst’s or Maloney’s mercury bougies.
The endoscope itself, the shaft of the Eder-Puestow
dilator, or a large size (45 F) Hurst’s bougie can be used as
guide shaft on which the esophageal prosthesis and the
pusher tube can be assembled (Figure 3). After liberal
lubrication, including the inside and the outside of the
prosthesis as well as the pusher tube, the whole assembly can
be passed perorally, as if performing an esophagoscopy with
a large-size endoscope. Patients usually tolerate this end-
stage procedure surprisingly well.
We prefer using the gastroscope as a guiding shaft because
it enables us to examine the position of the prosthesis in
place, to detect any complication that might have developed,
and finally by bending the tip of the scope, the whole
assembly can be pulled back, if necessary. The prosthesis also
VOL. 81— NUMBER 1— JANUARY 1984
47
can be withdrawn by using a grasping forceps or a polypec-
tomy snare.
After the endoprosthesis is seated properly, the pusher
tube is first twisted clockwise so that it can disengage from
the prosthesis; then, it is gently pulled back with the scope,
while the prosthesis in place is observed for any sign of
complication. This is followed by a chest x-ray and later a
barium swallow, to check once more the position of the
prosthesis and to look for any sign of a complication.
Complications related to the procedure, in a series of 200
patients, are reported as follows:6-10 bleeding, 1.5 percent;
perforation, 8 percent; pressure necrosis, 4 percent; migra-
tion of the prosthesis, 17 percent; and obstruction of the
prosthesis by tumor overgrowth, 22 percent. In our series of
five patients, we have not seen any significant bleeding.
There has been one perforation and frequent obstruction of
endoprosthesis by food which was dislodged easily by a small
Hurst bougie or by the endoscope itself. When the patients
were taught to wash down the food with water, this com-
plication was reduced significantly. We did not see any
obstruction due to tumor overgrowth, probably because we
always used radiotherapy as an adjunct to endoprosthesis.
Migration of the endoprosthesis can be prevented by adding
a distal retaining flange to it (Figure 3).
CONCLUSION
Although carcinoma of the esophagus is a progressive,
debilitating, and fatal disease, peroral dilatation and en-
doprosthesis, with or without radiotherapy, can provide
adequate palliation in the great majority of patients. Life is
not prolonged, but its quality is dramatically improved.
Endoprosthesis immediately relieves the dysphagia and
sialorrhea, prevents aspiration pneumonia, and gives the
patient a chance and satisfaction to resume normal eating
and nutrition. It also allows the patient to spend as much
time as possible out of the hospital, in the comfort of his or
her home.
REFERENCES
1. Rorenberg JC, Schwade JG, Vaitkevicius VK: Cancer of th |
esophagus, in DeVito VT, Heilman S, Rosenberg, SA (eds): Cancer
Principal and Practice of Oncology. Philadelphia, PA, Lippincqt
1982, pp. 499-533.
2. Lowe WC: Survival with carcinoma of the esophagus. An
Intern Med 77:915-918, 1972.
3. Boyce HW Jr: Medical management of esophageal obstructio
and esophageal-pulmonary fistula. Cancer 50:2597-2600, 1982.
4. Boyce HW Jr: Approaches to management of cancer of th
esophagus. Hosp Prac 17:108-124, 1982.
5. Kelsen D: Treatment of advanced esophageal cancer. Cance
50:2576-2581, 1982.
6. Sivak MV Jr: Therapeutic endoscopy of the esophagus.5«^
Clin North Am 62:807-820, 1982.
7. Skinner DB, Dowlatshahi KD, DeMeester JR: Potentially I
curable cancer of the esophagus. Cancer 50:2571-2575, 1982.
8. Howard M, McCallum RW: A modified technique for perora •
placement of an esophageal prosthesis. Gastrointest Endosc i
62:805-820, 1982.
9. den Hartog Jager FC, Bartelsman JF, Ttytgat GN: Palliative j
treatment of obstructing esophagogastric malignancy by endoscopic :
positioning of a plastic prosthesis. Gastroenterology 77:1008-1014.
1979.
10. Adams CL: The complications of endoesophageal tubes. Jjj
Thorac Surg 51:685-693, 1966.
11. Palmer ED: Peroral prosthesis for the management of in-
curable esophageal carcinoma. Am J Gastroenterol 59:487-498, 1973.
12. Moss AA, Schynyder P, Ruedi FT, et al.: Esophageal
carcinoma: Pretherapy staging by computed tomography. AJR
136:1051-1056, 1982.
13. Bralow SP: Diagnosis and staging of esophageal and gastric
cancer. Cancer 50:2566-2570, 1982.
14. Goodner JT: Surgical principles of resection and reconstruc-
tion, in Rubin P (ed): Cancer of the Gastrointestinal Tract. American
Cancer Society, Inc. New York, NY, 1974, pp. 17-19.
15. Fleischer D: The current status of gastrointestinal laser activi-
ty in the United States. Gastrointest Endosc 28:157-161, 1982.
16. Girardet RE, Ransdel HT, Wheat MW: Palliative intubation
in the management of esophageal carcinoma. Ann Thor Surg
18:417-430, 1974.
17. Boyce HW Jr. Palmer ED: Instruments for esophageal dilata-
tion, in Boyce HW Jr, Palmer ED (eds): Techniques of Clinical
Gastroenterologv. Springfield, IL, Charles C. Thomas, 1975, pp.
226-236.
48
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Vcute Radiation Pneumonitis
TUART SILBERSTEIN, M.D., DANIEL MALCOLM, M.D.,
VALYNNE V. BRAUN, M.D., A. OLUSEGUN FAYEMI, M.D., Teaneck*
\ patient with lymphosarcoma and pleural effusion was treated with
;hemotherapy and radiation therapy to the affected lung. Clinical
'emission resulted and the chest x-ray became normal. One week later,
>he developed an asymptomatic interstitial pulmonary infiltrate,
vhich biopsy proved to be acute radiation pneumonitis. This case
illustrates an abrupt onset of acute radiation pneumonitis without
dyspnea, cough, or fever and demonstrates that the radiologic
distinction between acute and chronic radiation changes is not absolute.
The appearance of a new chest
roentgenographic infiltrate in an
immunocompromised host presents
a perplexing problem to the clinician. In the case of a patient
with a lymphoma who has received both chemotherapy and
radiotherapy, the differential diagnosis consists of extension
of the malignancy, opportunistic infection, and toxicity of
therapeutic agents. The appearance, location, distribution,
and time of appearance of the infiltrate are important
features leading to the correct diagnosis, especially in radi-
ation-induced lung disease. We report a case of radiation
pneumonitis that emphasizes how abruptly and atypically
this entity can appear.
CASE REPORT
A 56-year-old white woman with lymphosarcoma diag-
nosed by cervical lymph node and parotid gland biopsies in
1976 was treated with cyclical courses of cyclophosphamide,
vincristine, and prednisone. She did well until February
1981, when she developed dyspnea and a left chylous pleural
effusion. CAT scan revealed mediastinal lymphadenopathy;
a left pleural biopsy showed involvement by lymphosarcoma.
She then was treated with vinblastine and bleomycin; a total
dose of 150 mg of the latter was administered by continuous
infusion over ten days. There was no response to this
therapy; she subsequently was given radiotherapy consisting
of 4,500 rads to the mediastinum over Five weeks. At the
completion of the radiotherapy, there still was a large left
pleural effusion. In April 1981, she was treated with cyclical
courses of carmustine, procarbazine, and prednisone.
Lymphadenopathy and pleural effusion resolved, and a chest
roentgenogram on October 10, 1981, was normal (Figure 1).
One week later, she developed pancytopenia and a chest
roentgenogram revealed a left upper lobe streaky interstitial
infiltrate (Figure 2). She had no cough, dyspnea, or fever;
physical examination of the lungs was normal. Gram stain of
sputum revealed few polymorphonuclear leukocytes but no
organisms. Sputum culture grew normal flora only; blood
and urine cultures were sterile. There was no evidence of
recurrence of the lymphosarcoma. She underwent fiberoptic
bronchoscopy and transbronchial lung biopsy of the in-
volved portion of the lung under fluoroscopic guidance. The
bronchial mucosa appeared grossly normal.
*From Holy Name Hospital where Dr. Silberstein is Attending,
Department of Pulmonary Medicine; Dr. Malcolm is Director,
Division of Medicine; Dr. Braun is Attending Pathologist; and Dr.
Fayemi is Attending Pathologist. Correspondence may be addressed
to Dr. Silberstein, 133 Engle Street, Englewood, NJ 07631.
VOL. 81— NUMBER 1— JANUARY 1984
49
Figure 2 — Anterior-posterior view of chest taken one week iater,
demonstrating streaky interstitial infiltrate in left upper lobe.
PATHOLOGY
Microscopically, the lung parenchyma showed thickening
of the alveolar septa by edema, fibrosis, and mild
mononuclear inflammatory infiltrate. Hyaline membranes
partially lined the wall of occasional alveoli. Hyperplasia of
alveolar lining cells with large bizarre hyperchromatic nuclei
and foamy cytoplasm also was observed (Figure 3). Some
blood vessels showed myointimal proliferation; rare foamy
cells in the intima were seen (Figure 4). Cytologic changes
similar to those seen in the alveolar lining also were observed
on the bronchial epithelium. These histopathologic alter-
ations are characteristic of acute radiation pneumonitis.9
DISCUSSION
Radiation-induced lung disease can take the form of acute
radiation pneumonitis or late-onset radiation fibrosis. The
statistics are varied as to the incidence, but Gross estimates
that 10 to 15 percent of patients receiving radiotherapy to the
lungs develop clinically appreciated, radiation-induced lung
disease.1 Acute radiation pneumonitis usually ensues two to
three months following completion of therapy; the range,
however, can extend from two weeks to greater than six
months. The most common symptoms are dyspnea, cough,
and fever which can be high and spiking. The physical
examination usually is unremarkable but tachypnea,
cyanosis, and evidence of pulmonary consolidation may be
observed. The earliest roentgenographic feature observed
rarely consists of an area of radiolucency.2 More common is
a ground-glass haze with sharp borders corresponding to the
port of the radiotherapy. An air bronchogram may be
Figure 3 — Lung biopsy showing thickening of alveolar septa by
edema, fibrosis, and mononuclear inflammatory cells. Enlargec
alveolar lining cells (cuboidal and polygonal) are present
Hyaline membrane (arrows) partially lines the wall of an occa
sional alveolus.
Figure 4 — Artery showing myointimal proliferation with rare
foam cells. Bizarre large alveolar cells are seen at upper right-
hand corner.
visualized and alveolar and nodular infiltrates are observed,
albeit infrequently. Pleural effusion, when present, usually is
small and once established does not increase.
The majority of patients with radiation pneumonitis be-
come asymptomatic over a period of months; however,
nearly all will develop roentgenographic evidence ol
pulmonary fibrosis in the area of the previous pneumonitis.
While the time course is variable, roentgenographic changes
from pneumonitis to fibrosis progress over a period of six
months to one year. An occasional patient, however, will
show interstitial fibrosis without preceding symptoms of
radiation pneumonitis.3 The majority of patients with in-
terstitial fibrosis are asymptomatic, though a few will have
extensive disease leading to chronic respiratory failure and
cor pulmonale.4 Once established, the roentgenographic
changes are permanent.
Factors known to increase the likelihood of radiation
pneumonitis are large radiation dose, short course of thera-
py, treatment of a large volume of lung,5 previous radiation
therapy,6 concurrent chemotherapy,7 and steroid with-
drawal.8 One can speculate that the antecedent therapy with
bleomycin played a role in determining the speed and nature
of this patient’s roentgenographic changes. However, not
only was the dose of bleomycin not large, but more than six
months elapsed between the bleomycin therapy and radi-
ation and the subsequent evolution of atypical pulmonary
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
50
infiltrate. Hence, synergism between bleomycin and radi-
ation most probably would not explain the occurrence of the
atypical presentation.
CONCLUSION
This case demonstrates how abruptly the changes of
radiation pneumonitis can develop. We were fortunate to
have had a chest x-ray that was normal one week prior to the
abnormal x-ray. The radiologic change exhibited was an
interstitial change usually interpreted as chronic radiation
fibrosis; lung biopsy, however, demonstrated changes of
acute radiation pneumonitis.
One can conclude that the radiologic distinction between
the acute and chronic radiation changes is not absolute. The
presence, then, of rapid development of a streaky interstitial
infiltrate should not preclude the diagnosis of radiation-
induced lung disease.
REFERENCES
1. Gross MJ: Pulmonary effects of radiation therapy. Ann Intern
Med 86:81-82, 1977.
2. Warren S, Spencer J: Radiation reaction in the lung. Am J
Roentgenol 43:682-701, 1940.
3. Lipshitz HZ, Southard ME: Complications of radiation thera-
py: The thorax. Semin Roentgenol 9:41-49, 1974.
Fried JR, Goldberg H: Postirradiation changes in the lung and
thorax. Am J Roentgenol 43:877-895, 1940.
5. Evans WA, Leucutia T: Intrathoracic changes induced by
heavy radiation. Am J Roentgenol 13:203-220, 1925.
6. Brady LW, Germon PA, Caudler L: The effects of radiation
therapy on pulmonary function in carcinoma of the lung. Radiology
85:130-134, 1965.
7. Phillips TL, Wharam MD, Margolis LW: Modification of
radiation injury to normal tissues by chemotherapeutic agents.
Cancer 35:1678-1684, 1975.
8. Castellino RA, Glatstein E, Turbow MM, et al.: Latent
radiation injury of lungs or heart activated by steroid withdrawal.
Ann Intern Med 80:593-599, 1974.
9. Fajardo LF, Berthrong M: Radiation injury in surgical
pathology, a review article. Am J Surg Pathol 2:159-199, 1978.
VOL. 81— NUMBER 1— JANUARY 1984
51
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
VIEDICAL HISTORY
Autopsies at Newark City Hospital,
1908 to 1911
VILLIAM D. SHARPE, M.D., South Orange*
Despite considerable real poverty, between 1908 and 191 1, Newark
vas a much safer and less violent place to live than now, based on a
•eview of autopsies at Newark City Hospital.
During the decade before the first
World War, Newark — the largest
city in New Jersey — was a prosper-
ous industrial and trading center with a population, for
Health Department purposes, of about 348,000. In 1910, its
death rate was 16.64/1,000 and its city death rate "excluding
hospital mortality” was 12.12/1 ^OO.1 It was a blue collar
town with strong ethnic traditions; it was not greatly dif-
ferent from the other industrial cities of a prosperous
Northeast. Newark had a distinguished medical community,
some of whom had international reputations.
Newark City Hospital was founded in 1883, and the main
building — four stories with basement, of red brick — was
built in 1899 at a cost of $450,000. From 1908 to 191 1, it had
approximately 250 beds and, for the time, was a large
hospital. Twelve interns, beginning their two-year terms at
ijStaggered three-month intervals, cared for their patients
under the supervision of a voluntary and wholly unpaid
attending staff drawn from the best physicians and surgeons
in the community. Newark had other hospitals at that time:
Saint Michael’s, Babies, Saint Barnabas, Saint James, Ger-
man Hospital, Women and Children, Eye and Ear, and Beth
[{Israel. Some of these survived, others have merged or fled to
the suburbs. There also were a variety of refuges, alms-
houses, private sanatoria, and private hospitals, some of
them little more than a private residence with an operating
room for the use of a single surgeon. In 1910, 1,558 deaths
occurred in Newark hospitals and kindred institutions: 625
were in Newark City Hospital (40 percent of the total) and
799 in the other eight hospitals listed (51 percent of the total
number of hospital deaths). We may conclude that these
smaller institutions played a very minor role in Newark’s
1910 medical care scene.1
In 1910,' ty pical of the years with which we are concerned,
part-time physicians employed by the City Health Depart-
ment sent 1,879 patients to Newark hospitals, 592 of them to
the Newark City Hospital; 32 percent of those sent to the
hospital by city physicians consulted by patients who did not
have their own private physicians. The rest of the breakdown
is as follows: 45 (2 percent), Hospital for Women and
Children; 23 (1 percent), Home for Crippled Children; 270
(14 percent), Eye and Ear Infirmary; 277 (15 percent), Babies
Hospital; 160 (9 percent), Newark Tuberculosis Sanatorium;
128 (7 percent), Saint Michael’s Hospital; 93 (5 percent),
Saint Barnabas Hospital; 87 (5 percent), Saint James Hospi-
tal; 98 (5 percent), German Hospital (now Clara Maass); and
106 (6 percent), Beth Israel.
Of the 1,104 patients sent by city physicians to general
hospitals, 592 (59%) went to Newark City Hospital. This was
an adequate sample and sufficient evidence that City Hospi-
tal then as now was the main source of hospital care for the
medically indigent.1
I will review the autopsies performed by Dr. Harrison
Martland between October 1908, and the end of 1911 to
describe the patterns of disease at that hospital at that time
to learn about the urban poor Newark City Hospital served.
Harrison Stanford Martland was born in Newark in 1883; he
graduated from Western Maryland College in 1901 and from
the College of Physicians and Surgeons of Columbia Univer-
sity in 1905. Dr. Martland spend 18 months as an intern at
the New York City Hospital, then on Blackwell’s Island in
the East River, and for a year was assistant pathologist at the
Russell Sage Institute, New York. In the fall of 1908, he was
appointed pathologist to Newark City Hospital. Until 1920,
he had no secretary. He spent his professional life at Newark
City Hospital, lived at 180 Clinton Avenue, retired after a
cerebrovascular accident in 1952, and died in 1954. 2 This
report is based on the first-bound volume of Martland’s
autopsy protocols in the archives, UMDNJ, Newark; others
*A portion of this paper was read at a meeting of the Medical
History Society of New Jersey, October 20, 1982, and at the Section
on Medical History, New York Academy of Medicine, May 25,
1983. Correspondence may be addressed to Dr. Sharpe, 62 Univer-
sity Court, South Orange, NJ 07079.
VOL. 81— NUMBER 1— JANUARY 1984
53
TABLE 1
Newark City Hospital Autopsy Outline, 1908-1911
Pathological Laboratory of the Newark City Hospital
History No Autopsy No
Name Age Source
Date of Death Date of Autopsy
Diagnosis Anatomica
Cerebrum
Medulla spinalis
Cor
Pulmo (Sinistra
(Dextra
Lien
Glandula Sinistra
Suprarenalis dextra
Ren (Sinistrum
(Dextrum
Duodenum
Ventriculus
Pancreas
Hepar
Intestinum tenuum
Intestinum crassum
Tractus genito-urinarius
Systemum lymphaticum
Telae serosae
Os et larynx
Abnormalitates anatomicae
Laesiones alterae
Causa mortis
Path
in the series, and the contemporaneous patient records, have
perished.
THE PROTOCOLS
The autopsy protocols themselves are extremely terse, and
sometimes provide only the patient’s surname and a few
words of description. A Latin outline was printed, the
diagnosis anatomica, on a good grade of 16-pound bond
paper measuring 10y2 by 14 inches. These were completed,
very sketchily, by entering a diagnosis rather than a descrip-
tion or organ weights, in ink, speared on a spindle file, and
eventually collected into heavy canvas-bound folios about 3
inches thick. Martland started by describing his findings in
Latin, but soon gave this up and wisely reverted to English.
Table 1 illustrates the format.
The protocols are numbered consecutively from 1 (4
October 1908) through 576 (29 December 1911) but, as Table
2 shows, 1 protocol was interpolated, 13 are missing, and
26 are blank — an accession number and perhaps a name are
provided, but nothing more; hence, our analysis will be based
on 537 protocols. Most of these are extremely brief, but 25 of
the printed sheets are accompanied by quite full gross
descriptions of which the printed diagnoses anatomicae pro-
vide accurate summaries. We do not know whether these 25
were exceptions, or whether full descriptions were prepared
for all of the autopsies but have been lost. Almost no clinical
information is provided, and there are neither microscopic
descriptions nor epicrises. Most data are entered in long-
hand. Martland performed all but 2 (478 and 481) of this
series, the 2 being done by a Dr. McKenzie during the third
week of June 1911 when Martland was apparently on
TABLE 2
Newark City Hospital Autopsy Study, 1908-1911:
Statistical Base (537 cases available for analysis)
Year
1908
1909
1910
1911
Opening accession number
1
37
201
387
Closing accession number
36
200
386
576
Protocols missing from book
0
5
6
2
Protocol present but blank
0
2
19
5
Interpolated protocol (i.e. 307%)
0
0
1
0
T otal autopsies for the year
36
164
186
190
Blank and missing protocols
0
7
24
7
Available for analysis
36
157
161
183
vacation. Sometimes, ten days elapsed between autopsies,
and sometimes Martland did 4 in one day. Surviving com-
plete protocols suggest that he usually spent about an hour
and a half on a discussion, about the same time an ex-
perienced autopsy surgeon still requires.
DO THESE AUTOPSIES REPRESENT
THE HOSPITAL POPULATION?
Martland usually recorded the number of deaths and the
number of autopsies performed during each month, and we
have this information for 33 of the 39 months under review.
The monthly autopsy percentage, that is, the percent of
deaths in hospital in which autopsies were done, ranged from
a low of 14 percent in September 1909 to a high of 35 percent
in April 1909. For these 33 months, the mean monthly
autopsy rate was 25.5 percent, the median, 25 percent, and
the mode, 27 percent. The median monthly autopsy rate
varied little from year to year; in 1909, 27 percent; in 1910, 27
percent; and in 1911, 25 percent. Most pathologists would
consider this an adequate sampling of Newark City Hospital
deaths, but only just adequate, although it is a higher
autopsy rate than now obtained in many teaching hospitals.
It is axiomatic that every patient buried without an
autopsy died of a correctly diagnosed, correctly treated
disease without undiagnosed complications. It also is cus-
tomary that clinicians, particularly those who really are not
interested in taking care of sick people, react to unwelcome
autopsy reviews by an attack on the statistical base of the
study. Hence it also is axiomatic that every autopsy series
reports atypical events. Granting that 537 autopsies is not a
sufficiently large number of autopsies to manipulate very
vigorously, Table 3 shows that our series comes from the
same population as the whole number of deaths in the
United States and in Newark during 1910 so far as can be
recalculated from the somewhat idiosyncratic nosologic clas-
sification used by the Newark health department at that
time.
There are some difficulties. Autopsy diagnoses, for quite
complicated reasons, may describe a somewhat different
population than that described by death certificates, and
death certificates notoriously are inaccurate. Syphilis, then as
now, often is underreported as a cause of death, with or
without autopsy. Newark had good drains and, until World
War II, an outstanding health department, so that typhoid
and the other enteric fevers were less frequent in Newark
than, for example, in New Orleans. Childhood diseases
usually were treated at home or in special children’s hospi-
tals. Whatever it was that physicians in 1910 termed
"gastritis, duodenitis, enteritis, and colitis” now is beyond
conjecture, but very likely it included such dissimilar entities
54
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 3
Some Common Causes of Death: Newark, United States (1910), and Newark City Hospital Autopsies, 1908-1911
Deaths/1 00,000/Year
U.S.*
Newark#
U.S.*
This
1910
1910
1970
Series
Tuberculosis, all forms
153.8
233
2.6
84
Syphilis, excl. aortic aneurysm
13.5
3
0.2
5
Typhoid, paratyphoid fevers
22.5
12
t
7
Scarlet fever, strep, throat
11.4
11
t
0
Diphtheria
21.1
29
t
4
Whooping cough
11.6
13
t
0
Measles
Malignant neoplasms, incl.
12.4
9
t
0
hemolymphatic
76.2
86
162.8
30
Diabetes mellitus
15.3
17
18.9
2
Major cardiovascular-renal
Influenza, pneumonia, excl.
371.9
313
496.0
77
newborn
Gastritis, duodenitis,
155.9
211
30.9
41
enteritis, colitis
115.4
20
0.6
7
Cirrhosis
13.3
20
15.5
8
Motor vehicle accidents
1.8
—
26.9
7
Accidental falls
15.4
—
8.3
10
Other accidents, incl. homicides
67.0
23
21.2
79
Suicide
15.3
21
11.6
18
Total, excluding fetal
1,470.0
1,664
950.0
379
*U.S. 1910 and 1970 death rates from United States Department of Commerce, Historical Statistics of the United States,
Colonial Times to 1970. Washington, D.C., 1975, vol. 1, pp. 49-64.
#Newark 1910 death rates have been calculated as a reasonable approximation from Annual Report of the Department of Public
Health, City of Newark, NJ, for the year 1910, pp. 100-107, and assumes a population of 348,000.
fFewer than 0.5.
TABLE 4
Ages at Death, Newark City Hospital Autopsies, 1908-1911
Number
Median
Mode(s)
Adults
Gender not stated
318
41 yr
35, 40 yr
Men
47
42 yr
42, 45 yr
Women
48
33 yr
30, 32 yr
Total adults
413
40 yr
22 yr
Children (below 10 years)*
Gender not stated
62
6y2 mo
1 mo
Boys
5
2'/2 mo
—
Girls
1
4 yr
—
Total children
68
7 mo
1 mo, 1 yr
‘Excluding 17 stillbirths and 9 "newborns.”
as acute myocardial infarction, perforated duodenal ulcer,
and carcinoma of the colon. City hospitals, then as now,
attract more than their share of accident victims. Overall,
this 1908 to 1911 autopsy series is fairly, if not completely,
representative of the world of disease as it was defined in
1910. The patient population is weighted toward low-income
groups who, when they fell ill, were attended by physicians
who were paid by the city rather than by private physicians.
HOW LONG DID THE PATIENTS LIVE?
The patient’s age not always is given in these protocols,
and a scatter plot of patients’ ages at death yields the usual
concentrations of deaths at 30, 35, 40, 45, 50, and 55 years
that suggests that these ages often were estimated. The
median age at death was 40 years (Table 4). Among the small
sample of men and women, the ages at death were 42 and 33,
respectively; the latter was partially but not entirely due to
the hazards of childbirth. It is when we turn to the children
that we see how uncertain the first year of life really was even
so late as 1910. The median age of death among children,
here defined as the completion of fewer than 10 years, was
seven months, with modes of 1 year and one month. Most
children died at home, or in one of the children’s hospitals in
Newark.
This relative youth at death — a median of 40 years for the
whole series — should be reviewed in the light of age-cohort
death rates for 1910 (Table 5). In 1910, death rates began to
double at 55 to 64 years, and in 1970, 65 to 74 years. But
among our population, the greatest number of deaths oc-
curred during the decade 35 to 44 years, and more died at 25
to 34 and 45 to 54 than at 55 to 64 years. In 1908 to 1911,
Newark City Hospital was not a place where old people came
VOL. 81— NUMBER 1— JANUARY 1984
55
or were abandoned to die. It was a place where young people,
many with young families, died early during what should
have been their most productive years.
OF WHAT DID THEY DIE?
Neither neonatal nor pregnancy- related deaths in this
series reflect the whole Newark experience because in 1908 to
1911, as in most parts of the United States, most confine-
ments took place at home.
Neonatal deaths at Newark City Hospital in 1908 to 191 1
came from a population that did not give birth at home
(Table 6). We suspect that high-risk or complicated deliveries
TABLE 5
Death Rates by Cohorts, U.S. 1910 and 1970, v Newark City
Hospital Autopsies, 1908-1911
Deaths/1 00,000/Year*
Newark
City
1910
1970
Hospital
Autopsies
Total
14.7
9.5
499“
Under 1 Year
131.8
21.4
51 “*
1 to 4 Years
14.0
0.8
19
5 to 14 Years
2.9
0.4
16
15 to 24 Years
4.5
1.3
42
25 to 34 Years
6.5
1.6
84
35 to 44 Years
9.0
3.1
109
45 to 54 Years
13.7
7.3
81
55 to 64 Years
26.2
16.6
61
65 to 74 Years
55.6
35.8
28
75 to 84 Years
122.2
80.0
8
85 Years and older
250.3
163.4
0
‘Excluding fetal deaths, from United States Department
of Commerce, Historical Statistics of the United States,
Colonial Times to 1970. Washington, D.C., 1975, vol. 1,
pp. 49-64. Addendum: Distribution of ages at death
from the 1910 Newark City Health Department report (p.
99) cannot be compared, but from the population of
348,000 were as follows: Under one year 1,242; 1 to 2
years, 278; 2 to 5 years 258; 5 to 20 years 357; 20 to 60
years 2,350; and over 60 years 1,299 deaths.
“Autopsy series excludes stillbirths.
“‘Ages are not stated in 32 records, and 17 protocols are
of stillbirths.
were admitted or transferred to the hospital only after
difficulties beyond the physician’s or midwife’s capacity were
encountered, and that many mothers in advanced com-
plicated labor arrived in the hospital too late for cesarean
section. This may be the best explanation for the number of
deaths attributed to traumatic or prolonged labor (6) and to
placental or cord problems (5) — a total of 11 out of the 38
neonatal deaths and stillbirths. Since neonatal intensive care
units were unknown until primitive incubators were in-
troduced after World War I, deaths from prematurity (7),
atelectasis neonatorum (5), and asphyxia (1) were more
frequent than now. Central nervous system anomalies
claimed 4 lives, and we cannot explain this incidence, which::
does seem unusually high. Three were merely stillborn, and 3
had fatal congenital syphilis. What was meant by infantile
nonrenal anasarca is not clear; perhaps it was hydrops fetalis.
Pregnancy- related deaths in this series probably do not
reflect the whole community’s experience. Other specialized
hospitals existed, most babies were born at home, and one is
not sure what percentage of mothers were hospitalized
(Table 7). Obstetric complications can be abrupt, unan-
ticipated, and without blood replacement and immediate
access to an operating room, rapidly fatal. Hemorrhage and
placenta previa claimed four mothers, and puerperal sepsis
killed five mothers. We do not know whether these five
women developed their sepsis at home and were admitted to
the hospital, or whether they were delivered and infected in
the hospital. Neither eclampsia nor renal complications of
pregnancy are without risk today.
Abortion, then illegal, claimed lives. Three women died of
postabortal sepsis, one of sudden air embolization while a
midwife was inducing abortion using a catheter, one de-
veloped peritonitis from a perforated uterus, and two died
from drugs taken to induce abortion. The youngest woman
who died of the effects of abortion was 20 years old and the
oldest was 27. Abortion then was a criminal offense but was
not a problem among teen-aged girls; neither knitting needles
nor coat hangers are mentioned in these autopsy protocols.
Pediatric deaths in this series are difficult to interpret;
many of the children who died when younger than ten years
old have been grouped among the infections (Table 8). Even
excluding those who died of diagnosed infections and the two
who died of malignant neoplasms, the results make grim
TABLE 6
Newark City Hospital Autopsies, 1908-191 1: Neonatal Deaths
Cause
Number
Median Age
(years)
Range
Prematurity
7
15 days
2 to 30 days
Traumatic or prolonged labor
6
SB
SB to 12 days
Atelectasis neonatorum
5
SB
SB to 1 day
Congenital anomalies:
Central nervous system
4
SB
SB to 1 day
Heart
2
3 mo
1 day; 6 mo
Multiple
1
8 days
Stillborn
3
SB
Maternal placenta previa or
hemorrhage
3
SB
SB to 1 day
Congenital syphilis
3
1 wk
SB to 7 mo
Asphyxia
1
1 day
Premature separation of placenta
1
SB
Prolapsed cord
1
SB
Infantile nonrenal anasarca
1
6 wk
SB = Stillborn
56
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 7
Newark City Hospital Autopsies, 1908-191 1: Pregnancy-Related Deaths
Median Age
Cause
Number
(years)
Range
Puerperal sepsis
5
30
26 to 32
Postabortal sepsis
3
25
21 to 26
Eclampsia
2
22.5
1 7 to 28
Postpartum hemorrhage
2
38
36 to 40
Postpartum renal failure
1
34
Postpartum anemia
1
24
Postpartum nephritis
1
31
Placenta previa
1
22
Postabortal peritonitis
1
27
Postabortal air embolism
1
20
Postabortal gastrointestinal
hemorrhage (took unknown drug
to induce abortion)
1
—
Mercury bichloride poisoning
(used as abortifacient)
1
22
TABLE 8
Newark City Hospital Autopsies, 1908-
1911: Pediatric Deaths
Median Age
Cause
Number
(years)
Range
Malnutrition
4
6 mo
3 to 12 mo
Marasmus
3
60 days
40 to 120 days
Congenital herniation of cecum
into duodenojejunal fossa
1
6 yrs
Intussusception
1
13 mo
Acute enterocolitis
1
1 yr
Empyema
1
16 mo
Aspiration of vomit
1
8 days
Exposure, asphyxia
1
2 mo
Exposure
1
10 mo
Hydrocephalus
1
18 mo
Sepsis
1
10 days
Gastroenteritis
1
6 mo
Streptococcal peritonitis
1
11 mo
TABLE 9
Newark City Hospital Autopsies, 1908-1911.
Cardiovascular Deaths
Cause
Number
Median Age
(years)
Range
Bacterial endocarditis
5
27
11 mo to 48 yr
Mitral stenosis
5
40
20 to 66
Myocarditis
5
55
35 to 65
Aortic regurgitation
4
48.5
40 to 52
Rheumatic bacterial endocarditis
2
47.5
42 to 53
Chronic aortic endocarditis
2
49.5
42 to 57
Mitral insufficiency
2
42
32 to 52
Patent foramen ovale
1
42
Syphilitic heart disease
1
35
Combined aortic and mitral stenosis
1
31
Coronary thrombosis
1
47
Hypertrophied dilated heart with
fatty degeneration of coronary
arteries
1
62
Myocarditis with atheromatous
coronary arteries
1
50
Cardionephritis
1
21
Pulmonary embolus
1
38
Ruptured thoracic aneurysm
1
41
Heart failure
1
—
VOL. 81— NUMBER 1— JANUARY 1984
57
TABLE 10
Newark City Hospital Autopsies, 1908-191 1: Digestive Diseases
Median Age
Cause
Perforated gastric or duodenal ulcer
Strangulated hernia
Ruptured appendix
Ileus from fibrous band obstruction
Acute peritonitis
Acute gangrenous colitis
Sigmoid volvulus
Cirrhosis of liver
Hemorrhagic pancreatitis
Choledocholithiasis with ascending
cholangitis
Multiple liver abscesses from
suppurative cholangitis
Hepatitis
Number
(years)
Range
6
43
28 to 60
2
30.5
22 to 39
1
3
1
33
1
53
1
27
1
65
8
46.5
34 to 57
3
45.5
41 to 50
1
26
1
14
1
70
TABLE 11
Newark City Hospital Autopsies, 1908-1911: Renal Diseases
Cause
Number
Median Age
(years)
Range
(Chronic) nephritis
16
46.5
23 to 70
Chronic nephritis with uremia
6
34
29 to 59
Chronic Bright’s disease
3
67
25 to 70
Acute Bright’s disease
2
44
38 to 50
Complications of urethral stricture
2
50
47 to 53
Post scarlatinal nephritis
1
25
Rupture of urethra
1
—
Renal calculi
1
52
Suppurative cystitis with
pyelonephritis
1
22
Pyelonephritis
1
47
reading. Malnutrition, marasmus, exposure combined with
asphyxia, and exposure alone account for 9 of the 18 deaths
in this group. These deaths very probably represent aban-
doned and neglected children, the oldest of whom was 12
months old, and surely constituted child abuse at least, and
perhaps attempts at homicide by neglect.
Cardiovascular deaths differed substantially in their pat-
tern in 1908 to 191 1 from now, but interpretation of autopsy
diagnoses without histologic confirmation is hazardous
(Table 9). It was not until World War I that physicians began
to take seriously the possibility that heart disease could be
treated; hence, most of the diagnostic classifications that we
now find intelligible were developed between the world wars.
Rheumatic heart disease was a very frequent cause of
death and disability until ignorant general practitioners
began to treat sore throats using antibiotics without waiting
for bacterial culture reports. Most of the endocarditis and
valvular heart disease in our series reasonably can be at-
tributed to rheumatic heart disease. Thus, 17 of the 35
cardiovascular deaths in this series may be attributed to
rheumatic heart disease. Syphilitic heart disease probably
was responsible for the cases of aortic regurgitation and for
the one ruptured thoracic aneurysm. One case was signed out
only as “syphilitic heart disease.” Thus, infection — strep-
tococcal or treponemal — rather than arteriosclerosis caused
23 of the 35 cardiovascular deaths.
Arteriosclerotic heart disease’s contribution to the other
21 cardiovascular deaths may be difficult to assess very
accurately in retrospect. J.B. Herrick first described, in
English, the clinical features of sudden obstruction of the
coronary arteries in 1912, although the association between
disease of the coronary arteries and angina pectoris and
sudden death had been known at least since the 18th
century.3 Thereafter, what previously had been death from
“acute indigestion” gradually became death from coronary
thrombosis. Three of our autopsies describe what now we
would consider coronary artery disease: coronary throm-
bosis, myocarditis with atheromatous coronary arteries, and
hypertrophied dilated heart with fatty degeneration of coro-
nary arteries. We also may suspect that most of the five
deaths listed as "myocarditis,” in fact, were due to
myocardial ischemia, but without histologic confirmation,
we cannot be sure.
Digestive diseases causing death (Table 10) were domi-
nated by the six who died of the complications of perforated
gastric or duodenal ulcers, and the eight who died of
cirrhosis of the liver. Three deaths from acute hemorrhagic
pancreatitis would not be unexpected in any city hospital
population. Too few deaths from other digestive diseases
permit us to identify a pattern. The two who died from
strangulated hernias probably were compounded by late
presentation to the hospital.
Renal disease interpretation, like diseases of the
cardiovascular system 70 years ago, require caution. It is now
quite impossible to determine just what the 16 patients who
died of chronic nephritis really had (Table 11). We may
suspect that this was an all-inclusive vague diagnosis and
what was termed “chronic Bright’s disease” now is almost
uninterpretable. Chronic nephritis with uremia claimed 6,
and postscarlatinal nephritis claimed 1 victim, but these 7
58
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 12
Newark City Hospital Autopsies, 1908-
191 1: Infections
Median Age
Cause
Number
(years)
Range
Lobar or bronchopneumonia
41
40
1 wk to 78 yr
Tuberculosis:
Pulmonary
44
38.5
4 mo to 63 yr
Miliary
20
35
4 to 58
Meningitis
7
30
2 to 49
Intestinal
4
31
7 mo to 40 yr
Kidneys
2
48.5
35 to 62
Bladder
1
49
Peritonitis
1
78
Not otherwise specified
5
40
36 to 62
Erysipelas
5
38
8 mo to 57 yr
Typhoid fever
7
32.5
22 to 44
Diphtheria
4
3.5
6 days to 45 yr
Rabies
3
14
12 to 54
Tetanus
2
26.5
14 to 39
Malaria
1
33
“Sepsis":
Lung abscess, empyema
6
42.5
27 to 55
Streptococcal
1
50
Secondary to pyarthrosis
1
61
Peritonsillar abscess
1
58
Suppurative pyosalpinx
1
29
Gangrenous stomatitis
1
45
Not otherwise specified
1
35
TABLE 13
Newark City Hospital Autopsies, 1908-1911: Central Nervous System Diseases
Median Age
Cause
Number
(years)
Range
Bacterial meningitis
9
36
6 mo to 71 yr
Cerebral hemorrhage
8
55
45 to 70
Meningitis or brain abscess
following mastoiditis
4
16.5
3 to 30
Subdural hemorrhage
3
55
35 to 65
Cerebral thrombosis
3
41
37 to 45
Encephalomalacia
2
57
39 to 75
Poliomyelitis
2
8.5
7 to 10
Extradural hemorrhage, spinal cord
1
—
Cerebral hyperemia
1
35
Brain abscess
1
—
CNS syphilis
1
37
Multiple sclerosis
1
46
Acute ascending paralysis,
spinal cord
1
26
Skull fracture during epileptic fit
1
42
patients probably died from what we now would classify as
chronic glomerulonephritis of some sort.
Infections accounted for 159 of the 537 deaths in our series
for which we have even rudimentary diagnoses, and con-
stitute just under 30 percent of the total (Table 12). Lobar
pneumonia and bronchopneumonia, “captains of the men of
death,” took 41, while the various forms of tuberculosis
killed 84 — 15.6 percent of all of the autopsies during 1908 to
191 1 attributed death to one form or another of tuberculosis.
Deaths also occurred from infections that would now be
medical, or at least autopsy, curiosities: typhoid fever,
diphtheria, rabies, and tetanus. Malaria claimed 1 life and
erysipelas — before modern antibiotics was a properly
dreaded disease — killed 5. Generalized sepsis, our sep-
ticemia, from other infections accounted for 12 deaths.
Central nervous system disorders (Table 13) caused 38
deaths, but 13 of these were from bacterial meningitis and 1
from a brain abscess: bacterial meningitis then was common,
and meningitis or brain abscess was a frequent and lethal
complication. The 8 deaths from cerebral hemorrhage almost
certainly were related to untreated hypertension, but the
protocols provide neither heart weights nor measurements of
the left ventricular wall, so this must remain conjectural. The
3 deaths from cerebral thrombosis and the 2 from en-
cephalomalacia would now be ascribed to complications of
cerebral arteriosclerosis, although the patients with cerebral
thrombosis do seem a bit young. Subdural hemorrhage and
extradural spinal cord hemorrhage are usually post-
traumatic. One patient died from central nervous system
syphilis, 1 from multiple sclerosis, I from an ascending
paralysis, and 1 of a skull fracture sustained during an
epileptic fit. Two died of poliomyelitis, and we cannot be
VOL. 81— NUMBER 1— JANUARY 1984
59
TABLE 14
Newark City Hospital Autopsies, 1908-1911:
Miscellaneous Causes of Death
' UK
, 1
1
■
Cause
Number
Median Age
(years)
a
Range
Protocols blank
26
37.5
SB to 68 yr.
Alcohol related
Delirium tremens, “wet brain”
12
37
25 to 62
Acute alcoholism
1
56
Chronic alcoholism
1
57
Broke leg when drunk
1
36
|
Subdural hematoma from fall
when drunk
1
35
Endocrine diseases
Diabetes mellitus
2
55
50 to 60
Addison’s disease
1
16
Miscellaneous
Senility
2
70.5
70 to 71
Exhaustion
1
49
Progeria
1
16%
Pernicious anemia
1
—
Morphine given to a patient
with nephritis
1
—
Uremia with lung and kidney
infarcts
1
49
TABLE 15
Newark City Hospital Autopsies, 1908-191 1: Malignant
Neoplasms
Classification
Number
Ages
Colon
4
38,
43, 63, 78
Esophagus
3
40,
44, 45
Rectum
3
41,
60, 71
Uterine cervix
3
50,
52, 60
Chronic lymphatic leukemia
2
40,
45
Glioma, gliosarcoma
2
10,
53
Tongue
2
52,
66
Pancreas
2
52,
60
Hodgkin’s disease
1
35
Acute lymphatic leukemia
1
18
Jaw
1
60
Stomach
1
64
Larynx
1
70
Bronchus
1
40
Prostate
1
—
Endothelioma, pleura
1
8
Vulva
1
34
sure what “cerebral hyperemia” meant.
Alcohol directly caused 16 deaths, 12 during delirium
tremens or from alcoholic “wet brain” (Table 14). This total
of only 3 percent of city hospital deaths in 1908 to 1911 as
alcohol-related is remarkably low, probably from gross
underreporting. Without blood alcohol assays, there is no
way to determine how extensively alcohol may have con-
tributed to other illnesses, and particularly to accidents and
homicides.
Endocrine-related deaths include vo from diabetes
mellitus, patients aged 50 and 60 respectively, so that this was
likely to have been of the nonketogenic maturity-onset
variety. Juvenile diabetics did not live very long before the
availability of insulin. One 16-year old died of Addison’s
disease, but the record does not make its etiology clear.
Miscellaneous deaths include a 16y2-year-old girl who died
of progeria. She was a patient of Dr. William H. Martland,
Harrison Martland’s father. Senility claimed two lives and
exhaustion claimed one. One patient each died of pernicious
anemia, of uremia with renal and pulmonary infarcts
(etiology unknown), and one with nephritis who was unwise-
ly given morphine.
In the United States, in 1910, the annual death rate for
malignant neoplasms (including the hemolymphatic systems)
was 76.2/100,000, and in 1970, it was 162.8/100,000. Malig-
nant tumors (Table 15) contributed only 30 deaths to this
series — 5 percent of the whole. The most striking thing is that
only 1 death was due to bronchogenic carcinoma and,
indeed, in 1908 to 1911 bronchogenic carcinoma was a
pathologic curiosity. Moreover, none of the women in this
series died of cancer of the breast.
Table 3 reviews some common causes of death in 1910.
Comparing these against our autopsy series, diabetes
mellitus, cardiovascular disease, pneumonia, and gastritis
(i.e. enteritis, duodenitis, colitis,) are underrepresented in this
series. Motor vehicle accidents, homicides, and suicides are
overrepresented, perhaps because Martland was the cor-
oner’s physician. But deaths from malignant neoplasms in
our 1908 to 1911 autopsy series are only slightly fewer than
what would have been expected from the general death rates
at that time. It does not appear that patients with cancer
selectively stayed out of the hospital to any significant extent.
Not all of the increase in deaths from malignant neoplasms
between 1910 and 1970 can be dismissed as an effect of
longevity in the population or of better case finding. Two
generations ago pathologists very accurately could tell
benign from malignant, although their diagnostic classi-
fications were less complicated than ours. It is clear that they
saw proportionately fewer cancers than we do.
Accidental deaths (Table 16) tell us a good deal about the
environment — occupational and domestic — from which our
patients came; without clinical summaries, autopsies cannot
provide much background information. Of the 80 deaths
classified as accidental, how do we interpret the 25 for whom
we have only the bald diagnosis of “skull fracture”? One
patient also died of meningitis following an accidental skull
60
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 16
Newark City Hospital Autopsies, 1908-191 1: Accidental Deaths
Median Age
Cause
Number
(years)
Range
Skull fracture, not otherwise
specified
21
44.5
4 to 71
Automobile accident
6
50.5
8 to 84
Broken neck or back
5
40
25 to 62
Accidental gunshot
5
17
3 to 32
Trolley accident
4
45
35 to 57
Railroad accident
4
28
18 to 33
Multiple injuries, not otherwise
specified
3
42
30 to 47
Anesthetic (chloroform) misadventure
3
30
24 to 32
Hip fracture
3
70
67 to 73
Heat stroke
2
56
56 to 56
Wagon accident
2
65.5
52 to 79
Wood alcohol ingestion
2
37.5
30 to 45
Horse
2
42.5
29 to 56
Rib fractures with pneumothorax
or hemothorax
2
50
28 to 72
Illuminating gas
1
83
Hanging
1
—
Hit by brick
1
22
Motorcycle accident
1
46
Meningitis following skull fracture
1
56
Fractured pelvis jumping from
window at fire
1
23
Subpial hemorrhage, scalp hematoma
1
40
1
Falls: From window
1
30
From fire truck
1
50
Not otherwise specified
1
61
On railroad station platform
1
36
Down stairs
1
37
Off stoop of house
1
—
From scaffold
2
40.5
30 to 51
Down elevator shaft
1
16
fracture, 2 died of rib fractures with pneumothorax or
ijhemothorax, and 1 died of a scalp hematoma with subpial
hemorrhage. Eighteen accidental deaths involved various
modes of transportation: 6 automobile accidents, 4 trolley
car, 2 horse-drawn wagon, and 1 motorcycle, while 2 were
killed by horses in unspecified manners. Four died in rail-
road accidents, but it is not clear whether as employees or
as passengers because details simply are too sparse.
Accidental gunshot wounds killed five persons; the median
age was 17, and ranged from 3 to 32. Three died from
anesthetic mishaps, usually tonsillectomy. The anesthetic
was chloroform and usually the operations were done on
outpatients. Two drank wood alcohol, one died from il-
luminating gas at age 83, one was hit by a flying brick, and
one broke his pelvis jumping from a window at a fire. There
were five broken necks or backs, three cases of multiple and
not further specified injuries, three hip fractures, two heat
strokes, and one accidental hanging. Falls were frequent
causes of death: windows, fire trucks, railroad station plat-
forms, staircases, front stoops, scaffolds, and — inevitably — a
16-year-old boy was killed when he fell down an elevator
shaft.
Murder was much less frequent than in today’s large cities,
but was even then a young man’s game (Table 17). Gunshot
and homicidal skull fractures each took six lives, and one
each died of kicking, stabbing, assault with a shovel, and —
an act of truly Edwardian elegance — a hatpin wound of the
heart. The pattern of homicides (murder is a jury verdict) in
our series suggests random violence. None of the 16
homicides in this series looks like an assassination and,
although quite impressively violent street gangs existed in
large cities at the time, Newark’s Health Department report-
ing area recorded only 9 homicides during 1910. Crime never
was organized until Prohibition.
Suicide methods change with time. Gunshot was chosen by
four young victims, aged 23 to 34. Their elders took arsenic,
usually as Paris green, or inhaled carbon monoxide. Each of
two 21 year olds took morphine, easily available over the
counter, and five other suicide victims used, respectively,
bichloride of mercury, carbolic acid, a mixture of arsenic and
ammonia, bichloride of mercury and carbon monoxide, and
one unidentified poison.
CONCLUSIONS
What do these autopsy protocols tell us about the lives of
the people who died in Newark City Hospital between 1908
and 1911? Although our conclusions must be tentative, we
can offer some suggestions about what things were like for
the urban poor whom the hospital served at that time.
In 1908 to 191 1, prosperous citizens of Newark were born
and usually died at home. They often were operated upon at
home, or in small private hospitals. They did not come to
Newark City Hospital by choice, although they may have
been carried there by ambulance following an accident.
Hence, in 1908 to 1911, Newark City Hospital retained many
characteristics of late 18th and early 19th century charity
hospitals in that it provided care for those whose domestic
resources or network of human ties could not accommodate
VOL. 81— NUMBER 1— JANUARY 1984
61
TABLE 17
Newark City Hospital Autopsies, 1908-191 1: Homicides and Suicides
(\
Cause
Number
Median Age
(years)
Range
Homicides: -’il
Gunshot
6
32
28 to 38
Skull fracture
6
35.5
26 to 60
Hatpin wound of heart
1
—
Hit by shovel
1
30
Kick to abdomen
1
35
Stabbing
1
18
Suicides:
Gunshot
4
28.5
23 to 34
Arsenic, Paris green
4
62
48 to 69
Carbon monoxide
3
59
20 to 66
Morphine
2
21
21 to 21
Mercury bichloride
1
17
Arsenic and ammonia
1
16
Carbolic acid
1
—
Mercury bichloride and carbon
monoxide
1
34
Poison, not otherwise specified
1
34
their births, illnesses, surgical operations, or dyings.
In 1908 to 1911, poverty clearly left a great many people
no alternative to Newark City Hospital. Poor people do not
live as long as rich people, they seek medical advice later
during the courses of their illnesses, and their responses to
the stress of illness and injury sometimes are less effective
than they might be. Malnutrition, fatigue, chronic depres-
sion, hopelessness, and other intangibles are common among
the poor. Most of our patients died when they were between
25 and 54, and especially when they were between 35 and 54.
At the very stage in life when privileged or middle-class
citizens were getting nicely started in their lives and careers,
our patients were reaching the ends of theirs. To be blunt, as
late as 1910, the lives of many of the patients whom Newark
City Hospital served were as nasty, as brutish, and as short
as they would have been 100 years earlier.
Conventional wisdom regards tuberculosis and rheumatic
heart disease as related to poverty, to overcrowding, and to
marginal diet. We may suspect the same of the meningitis in
our series. Mortality from both tuberculosis and rheumatic
heart disease began to fall long before the development of
modern antibiotics as housing and diet improved, but we
safely can suggest that this improvement had not exerted its
full impact on the poor of Newark by 1910.
In 1908 to 191 1 Newark, patterns of death among children
— malnutrition, marasmus, exposure, asphyxia — suggest that
infanticide by neglect, man’s oldest form of population
control, still was operative. The complications of childbirth
were not problems for adolescent girls, and only 1 of the 19
mothers in our autopsy series was younger than 20. She was
17 — young, but by the standards of the time, nubile. Abor-
tion-related complications did not fill the wards, and in 1908
to 1911, deaths from “unplanned pregnancies” were only
peripheral concerns at Newark City Hospital. We therefore
may suggest that sexual lives were perhaps better disciplined
in Newark than now.
Cancer was not so frequent a cause of death as now is the
case. This change is real, and merits serious exploration
although no useful opinion can be offered as to why this is so
until a much larger statistical base permits us to assess the
relative impact of changes, over time, in the incidence of site-
specific tumors. The increase in bronchogenic carcinoma
alone during the past generation has affected the cancer
death rate enormously, but careful and accurate retro-
spective reviews might yield some provocative insights. Prior
to World War I, for example, cigarette smoking and wrist
watches were viewed widely as effeminate and macho men!
avoided both. Of our entire series, only one bronchogenic
carcinoma was recorded and no deaths that, on review,
seemed to be from chronic obstructive lung disease. We mayjj
suggest that whatever lifestyle or environmental factors
explain this increase in cancer deaths, they were less potent
or frequent two generations ago.
Old people were not abandoned in Newark City Hospital; j
it was neither a geriatric hospital nor a nursing home.
In 1908 to 191 1, murder was vastly less frequent than now,
and murderers ran a considerable risk of being executed. The
criminal justice system may have done things that would
upset the American Civil Liberties Union, but it seems to
have been effective at least in preventing murder. Deaths
from drug overdoses were unheard of, except when taken as
abortifacients or with suicidal intent. None of the autopsies
in this series suggested sexual abuse; we can be reasonably
sure that had such victims died in the hospital, Martland — as
the coroner’s physician — would have done the autopsy.
Our 1908 to 1911 autopsies include fewer homicides than
now would be the case, and no fatal sexual assaults. Certain
bacterial diseases now are curable that then usually were
lethal. There were far more deaths from such diseases as
tuberculosis and rheumatic heart disease, which generally are
attributed to poverty and which may be good indices of real
deprivation. More workers seem to have been killed at work
than now. But we also may have to suggest that despite
considerable real poverty, Newark then was a much safer
and less violent place to live.
REFERENCES
1. Annual Report of the Department of Public Health, City of
Newark, N.J., for the Year 1910.
2. Samuel Berg: Harrison Stanford Martland. New York, NY,
Vantage Press, 1978.
3. Herrick JB: Clinical features of sudden obstruction of the
coronary arteries. JAMA 59:2015-2020, 1912.
62
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
PEDIATRIC BRIEFS
Selected Abstracts with Comments*
Leiken SL: Minors' assent or dissent to medical treatment.
Pediatrics 102:169, 1983.
This essay by an oncologist argues for a flexible and indi-
vidualized approach to the inclusion of minor patients in
:reatment decisions. In general, children 14 years of age or
older have developed the elements of cognition required for
(rational consent. Voluntariness, i.e. independence from over-
whelming conformity needs, also is required for true consent.
•'Fourteen or 15 years of age, generally speaking, is the earliest
ithat children may be expected to dissent in the presence of
Hparents who already have agreed to a proposed treatment.
^However, the variability in psychologic development and in
other factors (i.e. social class or prior experience with illness
and hospitalization) is so great that no arbitrary age criteria
will suffice to determine how a child should be included in
the decision process.
The goal of such determination is to avoid disrespect for
the minor on the one hand and to avoid unrealistic expecta-
tions of competence on the other. The responsible health care
professional who makes or participates in the making of
these determinations will: (1) be informed by the work of
Piaget et al. on “levels” of cognitive development; (2) make
careful assessments of the individual minor’s “levels” of
psychologic and social development; and (3) honor the child
by respecting him/her at the “level” of competence which
a careful assessment demonstrates. This means, for example,
that if a minor is judged on good clinical grounds as being
able to assent meaningfully to proposed treatment and then
dissents, the dissent should be honored as well. Often,
however, a minor will not be assessed confidently as able
to decide autonomously. In such cases, there is an obligation
to inform and include the child when treatment decisions are
being considered by others. Here, the determination of com-
petence is not so critical. It is not respect for autonomy which
is at stake, but humane treatment and efforts to strengthen
the therapeutic alliance. Even so, there remains the general
obligation to deal with any patient openly and honestly.
Moreover, the decisions reached by physician and parents
should accommodate the minor’s needs and values, even
though he/she is not accorded the right to assent or dissent.
Comment: I agree wholeheartedly. The developmental ap-
proach to assessing competencies, and hence appropriate
involvement in decision making, makes great sense. Here is
another clear instance where psychological sophistication
and careful clinical assessment is required to give effect to
our moral commitments. Every pediatrician should know
about cognitive development (and its corollaries for concep-
tualization of illness). Every pediatrician should practice as-
siduously the assessment skills required to determine the
appropriate involvement of minors in treatment decisions.
The moral force behind these standards of knowledge and
skill is derived from the ethical obligation to provide auton-
omy to those individuals capable of assuming it, without
denying protection to those who are not. (D. Price, Ph.D,
Adj. Asst. Professor, Health Care Humanities)
Vu NV, et al.: How medical students learn. J Med Educ
58:601, 1983.
Medical school faculties have emphasized what students
should learn rather than how to learn. Recently, the Associa-
tion of American Medical Colleges stated that medical stu-
dents must be steered toward development of independent
and analytic learning skills. In a comprehensive analysis of
how students learn in the first two years at two United States
medical schools (one with a traditional curriculum, the other
with an “objectives-based mastery curriculum”), the authors
concluded that the medical students they studied would not
be effective lifelong learners because they adopted behaviors
antithetical to same. They did not have well-planned study
systems and they were not motivated to active searching of
learning beyond expectations of their teachers. There was
evidence of development of analytic skills, however. The
authors state “students do not possess independent learning
skills [upon entry] and seem not to develop them [during
the first two years].” They speculate that the curriculum in
the first two years may be so overloaded that “students adopt
only those learning behaviors which help them cope with
curriculum requirements. . .[and] the structure and frequen-
*Abstracts are from the Department of Pediatrics Newsletter,
UMDNJ-New Jersey Medical School, Vol. 8, No. 9, 1983. Selections
are made by Richard J. Rapkin, M.D., Medical Director of Chil-
dren’s Hospital, Newark, who is Editor; and by Coeditors, Franklin
C. Behrle, M.D., Professor and Chairman, Department of Pedi-
atrics, UMDNJ-New Jersey Medical School, and Shyan C. Sun,
M.D., Director of Neonatology, Children's Hospital, Newark. Cor-
respondence may be addressed to Dr. Rapkin, Children's Hospital
of New Jersey, 15 South 9th Street, Newark, NJ 07107.
VOL. 81— NUMBER 1— JANUARY 1984
63
cy of examinations in medical curricula may inhibit even the
most self-confident and independent student from learning
in his own way.” They recommend that “curriculum com-
mittees and faculty members need to create an environment
in which students can learn effectively and efficiently and one
which encourages . . . self-directed learning habits.” They
make four suggestions: ( 1 ) curricula with gradually less struc-
ture on students’ learning; (2) provision of time for indepen-
dent learning and reduction of amount of information re-
quired; (3) replace some examinations with self-evaluation
exercises; and (4) research the subject of curricula change and
its relation to student learning behaviors.
Duff GW, et al.: Fever and immunoregulation. Yale J Biol
Med 55:437, 1982.
Fever is mediated by a polypeptide (endogenous pyrogen
[EP]) produced by macrophages. Interleuken I is a macro-
phage-made-polypeptide which stimulates T lymphocyte
proliferation. Interleuken 1 and EP probably are identical.
Hyperthermia (in vitro cell studies) increases the T cell
response to EP. “If naturally occurring fever influences the
immune response in vivo to the extent suggested by our
observations in vitro, then the role of fever as a host defense
may warrant further examination. For example, antipyretic
drugs may be useful in autoimmune diseases where the im-
mune response is detrimental to the host, but when the
immune response is to the host's advantage (e.g. directed
against infections or neoplastic cells), then fever itself may
be beneficial. . . [These findings] call into question the cur-
rent indiscriminate use of antipyretic agents."
Gershel JC, et al.: The usefulness of chest radiographs in first
asthma attacks. N Engl J Med 309:336, 1983.
Three hundred seventy-one consecutive children over age
one year with initial wheezing episodes had radiographs. Of
those with “positive” films (abnormal beyond the usual find-
ings in asthma), 95 percent could be predicted clinically by
signs in combination: tachycardia, fever, and localized find-
ings (rales or decreased breath sounds). Routine radiographs
are not necessary in the vast majority of first-time wheezers
over age one.
Comment: I was brought up on “all that wheezes is not
asthma ' and urged to obtain a chest x-ray whenever seeing
a (presumed) asthmatic for the first time or whenever such
children warranted admission for status. This study did not
address the latter situation which remains, for me, a signifi-
cant illness requiring careful evaluation among which is a
chest x-ray. I am not looking for subsegmental atelectasis
(often mislabeled and mistreated as pneumonia) but rather
evidence of laterality (e.g. foreign body), pneumothorax or
pneumomediastinum, or significant underlying lung disease.
I will not quarrel with the authors' conclusion that chest
radiographs are superfluous in many patients with wheezing.
THE
These patients most often are seen in physician office prac-
tices and, I would guess, rarely get radiographs unless they'
are to be admitted. The latter patients are a different group
and until a large study is done on those, I will remain?
traditional in my approach.
Staheli LT: In-toeing and out-toeing in children. J Fartt Praci
16:1005, 1983.
Causes of in-toeing include: (1) Metatarsus adductus (of
which 85 percent resolve without treatment). Rigid deformity
or failure to resolve spontaneously in six to nine months isil
an indication for simple casting. (2) Internal tibial torsion
(which rarely persists). No treatment has been proved effec-
tive for the remainder. (3) Medial femoral torsion (this often
gets worse for a few years and then improves spontaneously).
No treatment is indicated since none has been proved effec-
tive. The only cause of out-toeing is tibial torsion and no
treatment is known. Rotational osteotomy for many of these
conditions is “one of the most risky operations in or-
thopedics.” Inappropriate therapies include shoe modi-
fications which are “ineffective, waste family resources, and
embarrass the child”. Orthotics have no place in manage-
ment of these conditions.
Comment: Dr. Staheli is a careful pediatric orthopedist.
My own beliefs are supported by his observations and litera-
ture review. In-toeing and out-toeing are rarely of signifi-
cance, usually are self-limited and, even if persistent, are only
cosmetic. There is no proved safe and effective treatment but
many expensive and dangerous ones. The physician should
beware and be resistant to proposed cures until evidence is
forthcoming.
Campbell JB, et al.: Foley catheter removal of blunt
esophageal foreign bodies. Experience with 100 consecutive
children. Pediatr Radiol 13:116, 1983.
One hundred consecutive children with blunt esophageal
foreign bodies were treated with a nonoperative method of
foreign body removal utilizing a Foley catheter. Dislodge-
ment was successful in 98 children. There were no complica-
tions. Performed properly, the technique is rapid and safe.
It precludes hospitalization and even the slight hazards of
endoscopy and general anesthesia.
( omment: I certainly agree with the approach of the above
writers in handling blunt esophageal foreign body
nonoperatively in the x-ray department under fluoroscopy
using the Foley catheter technique. This is a very old method
being reported frequently in the literature and should be kept
in mind in handling children with this type of foreign body.
Only children with a blunt esophageal foreign body are
candidates for this technique. If this method fails in remov-
ing the foreign body or successfully pushing it to the
stomach, the patient should be taken to the operating room
and, under general anesthesia, the foreign body should be
removed with instrumentation. (S. Saad, M.D., Asst.
Professor, Pediatric Surgery.)
JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
64
IMPAIRED PHYSICIANS PROGRAM
Monitoring
DAVID I. CANAVAN, M.D., Lawrenceville*
The high incidence of recidivism that
is associated with the diseases of
impairment; the frequency of in-
volvement with disciplinary boards at the hospital and state
level; and our responsibility to the public, the profession, and
the individual impaired physician mandate an effective pro-
gram for monitoring the continuing recovery of our clients.
Because of the ever-increasing number of physicians in our
program, it becomes more and more difficult for the medical
director to supervise personally all of the clients to the extent
that we would like. It is essential that a well-coordinated
network be available to assist in this critical function. There
now are several different phases of our monitoring program
in operation. The followup of each individual, however, is
tailored to that physician’s own special needs and the nature
of the impairment involved. We try to personalize this pro-
gram to the extent that it is possible.
PHASE I: FOLLOWUP CONTACT WITH THE INITIAL
REFERRAL SOURCE
In the experience of our program, the initial referral
usually is from a seriously concerned individual who cares
deeply about the impaired physician. These usually are close
colleagues, family members, office personnel, or hospital
staff members who continue in close contact with the re-
covering physician and are as intimately aware of the phy-
sician’s continuing recovery as they were of the downhill
spiral of his original impairment. These people are an excel-
lent and usually quite reliable source of information on the
doctor’s progress or the lack thereof.
PHASE II: COMMITTEE ON IMPAIRED PHYSICIANS
An important part of the role of the members of the
Committee on Impaired Physicians is their function as local
monitors. We have divided the state into-regions. Each re-
gion has a regional coordinator who is a member of our
Executive Subcommittee. Each member of the Committee is
assigned to one of the regional teams and has the responsi-
bility of monitoring the progress of physicians assigned to
him and reporting regularly on the physician’s recovery
either to the regional coordinator or directly to the medical
director. Very often the monitor is the same physician who
participated in the initial confrontation and, therefore, is
known to the physician client. Whenever possible, each phy-
sician client has an assigned local physician monitor.
PHASE III: THE MEDICAL DIRECTOR
The medical director in addition to, or occasionally in
place of, the local monitor, attempts to maintain personal
contact with all the physician clients in the program. He
takes over this responsibility if the physician lives in an area
of the state where there are no close monitors available. All
physician clients are made aware of their right of access to
the medical director at any time that they feel he can assist
them in any area of their recovery. For those physicians
whose problems are most severe, and often therefore most
involved, the medical director assumes the responsibility of
the burden of their followup. This close contact with a con-
cerned physician from the Committee on Impaired Phy-
sicians is a key element in the ability of the program to
succeed.
PHASE IV: ATTENDANCE RECORDS
One of the important aspects in assisting the recovering
physician in dealing with administrative issues at the hospital
or the State Board level is the ability to document the phy-
sician’s participation in a structured recovery program.
We have developed an attendance record card as one
means of providing this documentation.
It is a principle of the support group philosophy that
attendance is not taken at meetings of the groups. However,
when an individual member, for his or her own personal
needs, requires documentation, the group secretary is able
and authorized to confirm the member's attendance. The
attendance card is identified with the physician’s code
number so that if it is lost it does not reveal the identity of
the impaired physician to the person who finds it. This card
also assists us in documenting the frequency with which the
physician attends and enables us to measure performance
versus our recommendations.
*Dr. Canavan is Medical Director, Impaired Physicians Program.
Correspondence may be addressed to Dr. Canavan, MSNJ, Two
Princess Road, Lawrenceville, NJ 08648.
VOL. 81— NUMBER 1— JANUARY 1984
65
PHASE V: URINE MONITORING
In the case of physicians whose problem is the abuse of
drugs, other than alcohol, our most valuable documentary
tool is the ability to monitor the physician's urine for the
presence of mood-altering drugs. With the close cooperation
of the Division of Laboratories of the New Jersey Depart-
ment of Health, we have been able to structure a very effec-
tive program for the substance-abusing clients in our Pro-
gram.
The physician client presents himself or herself at one of
the 15 state-sponsored drug abuse clinics. Only the clinic
director is aware of the physician's identity. The physician
provides a fresh urine sample under direct observation. The
sample then is labeled with the physician's code number and
forwarded under the code number to the State Department
of Health laboratories in Trenton where it will be analyzed
for the presence of up to four different classes of mood-
altering drugs. Testing for a total of eight different classes
of drugs is available. Our office selects the four classes for
each specimen. We can vary this each time if we choose to
do so. We also control the randomicity of the specimens.
The test results are forwarded, under the code number
'
to MSNJ headquarters in Lawrenceville. Only two people
have access to the code: the medical director and his sec-
retary. j
Positive urine results immediately are pursued with thej
physician involved. There is occasional cross reactivity with
benign substances and these must be ruled out carefully. The
urine test results are very accurate. When a choice must be
made between the reliability of the urine and the reliability
of the client, the edge goes to the urine test.
Urine monitoring, in these cases, serves three important
functions: it is a constant reminder to our recovering col-
leagues that “big brother" is watching; it is an excellent early
warning system and promptly alerts us when our client be-
gins to “slip”; and it is excellent documentation of the drug-
free state for submission to administrative boards.
It should be apparent that the Impaired Physicians Pro-
gram considers close monitoring of our clients a major re-
sponsibility. Without it, the initial gains of early identifi-
cation, confrontation, appropriate treatment, aftercare, and;
support groups easily could be lost
I
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the “con-
spiracy of silence’' that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle” on a suffering colleague is indeed an ACT OF LOVE!
Call Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
66
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
A
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VOL. 81— NUMBER 1— JANUARY 1980
67
DOCTORS’ NOTEBOOK
Trustees’ Minutes
November 20, 1983
A regular meeting of the Board of
Trustees was held on Sunday, November
20, 1983, at the Executive Offices in
Lawrenceville. Detailed minutes are on
file with the secretary of your county
society. A summary of significant ac-
tions follows:
Report of the Executive Director . . .
(1) MSNJ Financial Statements . . . Ap-
proved the financial statements for the
periods ending September 30 and Octo-
ber 31, 1983.
(2) State Board of Medical Examiners
(SBME) . . .
(a) Approval of Letters of Admonishment
and Criticism . . . Noted that before let-
ters of admonishment are issued, phy-
sicians will have the opportunity for a
hearing with the SBME.
(b) Proposal To Amend Ruling on
Advertising . . . Was advised that the
Board will have the opportunity to re-
view and comment on amendments to
the ruling on advertising when the
proposal is developed by the SBME.
(3) Litigation
(a) SBME v Strauch and Aluri . . .
Noted that the decision of the SBME in
both cases was upheld by the Appellate
Division; a petition for certification has
been filed by the New Jersey Supreme
Court.
(b) Subordinated Loan . . . Noted that
the trial date was set for December 14,
1983, in Tax Court.
(4) Professional Liability Rates . . . Was
informed that the Board of Governors
of the Medical Inter-Insurance Ex-
change of New Jersey has voted to file
a rate request that will increase all pro-
fessional liability rates by 13.7 percent
effective February 1984.
(5) Licensing and Regulation of Athletic
Trainers — A-3262 . . . Approved the re-
ferral of the bill to the chairmen of the
Council on Legislation and the Commit-
tee on Sports Medicine to determine
whether the amended version possibly
could produce a change in MSNJ’s po-
sition of active opposition.
UMDNJ Report . . .
(1) New Jersey Blood Banks ... Was
alerted to the possibility that an article
to be published in the New England
Journal of Medicine may cause a prob-
lem for blood banks in New Jersey; the
article reports on cases of AIDS involv-
ing persons who received blood trans-
fusions.
(2) President’s Contract . . . Con-
gratulated Dr. Bergen on receiving the
approval of UMDNJ’s Board of
Trustees for the extension of his term as
president through June 30, 1989.
New Jersey Hospital Association . . .
(1) Disciplinary Proceedings and
Malpractice Actions . . . Noted that the
report form used for reporting dis-
ciplinary actions or proceedings against
a physician as well as any malpractice
actions should state that the final dis-
ciplinary action was taken against the
physician by the governing board of a
health care facility and does not involve
an administrative matter.
(2) Licensing and Accreditation . . .
Noted that the Board of Trustees of the
New Jersey Hospital Association en-
dorsed the following position:
a. Hospitals should have the right to vol-
untarily use Joint Commission accreditation
as an alternative to duplicate licensing
surveys.
b. The hospital would submit to the De-
partment of Health a copy of its Joint Com-
mission survey results.
c. When the Department of Health utilized
the Joint Commission survey results for
purposes of assuring compliance with licens-
ing standards, it would agree to maintain the
strictest confidentiality of the Joint Com-
mission findings.
d. The Department of Health would ac-
cept accreditation for licensing purposes with
the understanding that the Department
would need to retain the right to validate or
audit.
(3) Definition of Death . . . Noted that
with the change in wording in bill S-140
(Uniform Determination of Death Act)
which refers to the discontinuance of
“life support” measures, the New Jersey |
Hospital Association now supports the
legislation.
(4) Facility Definition . . . Agreed that a
strong effort should be made to reach a
mutually acceptable form with the New
Jersey Hospital Association on the is-
sues involved before legislation is in-
troduced.
MSNJ Student Association . . . Received
as informative the monthly report of the
MSNJ Student Association noting mem-
bership figures, a donation of $500 from
the Essex County Medical Society, sug-
gestions for speakers for business of
medicine seminars, and mention of the
first issue of the student newsletter.
Council on Medical Services . . .
(1) Corporate Restructuring of New Jer-
sey Hospitals . . . Approved and effected
the following recommendations:
That the Medical Society of New Jersey
objects to the fact that it was not asked to
have a member participate in the delibera-
tions of the Blue Ribbon Committee on an
issue bearing directly on the practice of medi-
cine.
That the Medical Society of New Jersey
objects to recommendation #1 contained in
the Blue Ribbon Committee’s report, which
recommends broader application of regu-
latory principles to all providers of health
care.
That the Medical Society of New Jersey
wishes to participate in any discussions on the
development of a definition of “core” hospi-
tal services if such a definition is needed.
Referred back to the Council on Medi-
cal Services for an explanatory state-
ment on unbundling, the following rec-
ommendation:
That the Medical Society of New Jersey
understands and recognizes the economic
need for some hospitals to unbundle.
Approved the following recommen-
dation:
That the Board of Trustees make a strong
statement, with explanations, opposing the
68
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
application of certificate of need regulations
to physicians’ private offices, and that all the
recommendations be conveyed to the Com-
missioner of Health.
(2) AMA Council on Medical Service
Report on Physician Reimbursement . . .
Approved the following recommen-
dation:
That the Medical Society of New Jersey
supports pluralistic methods of reimburse-
ment to include, but not limited to, UCR,
private billing, and indemnification. (Italics
indicate an editorial amendment by the
Board.)
(3) Resolutions #14, #15, and
#16 — House of Delegates . . . Referred
the following recommendation back to
the Council on Medical Services for re-
view and a restatement:
That the Board of Trustees strongly
protests the legislation that now governs the
generic prescribing system on the grounds
that it affects adversely the quality of medical
care and increases physician liability in
prescribing drugs over which he has very little
control.
(4) Statewide Health Coordinating
Council (SHCC) . . . Approved the fol-
lowing amended recommendation:
That the Medical Society of New Jersey be
allowed to designate a representative to the
Statewide Health Coordinating Council
(SHCC).
Council on Public Relations . . .
(1) Health Research and Educational
Trust of New Jersey (HRET) . . . Voted
to disapprove the following recommen-
dation:
That the Board of Trustees approves the
purchase of a TV dish in order to participate
in the Healthcare Information Network Pro-
gram.
(2) New Jersey Network . . . Approved
the following recommendation:
That the Board approves spending $5,000
to support health programs on New Jersey
Network-Consumer Line.
Committee on Medicaid . . .
Medicaid Personal Physicians Plan . . .
Approved the following amended rec-
ommendation:
The Medical Society of New Jersey does
not endorse the Medicaid Personal Physicians
Plan as currently offered. The Society urges
the Division of Medical Assistance and
Health Services to reconsider the Pilot Project
presented by the Division in September of
1980 for Atlantic and Mercer Counties, since
it will serve as a means of improving the
provision of medical care to Medicaid recipi-
ents.
Committee on Maternal and Child Care
(1) Third Trimester Abortions (Resol-
ution #17) . . . Approved the following
recommendation:
That the Burlington County Medical So-
ciety be requested to reconsider Resolution
#17 (Third Trimester Abortions) and resub-
mit it in proper form and content if they are
interested in pursuing this issue further.
(2) Guidelines for Perinatal Study Con-
ferences . . . Approved the following rec-
ommendation:
That the Medical Society of New Jersey
endorses the “Guidelines for Perinatal Study
Conferences,” which will be distributed by
the State Department of Health through the
Maternal and Child Health Programs.
(3) Task Force on Fetal Alcohol Syn-
drome . . . Approved the following rec-
ommendation:
That the Medical Society of New Jersey
endorses the educational goals of the Task
Force on Fetal Alcohol Syndrome and urges
all physicians caring for women of child-bear-
ing age to bring the dangers of drinking to
their attention.
Executive Subcommittee, Committee on
Impaired Physicians . . .
(1) Full-time Alcoholism Counselor ...
Noted that there will be further dis-
cussion concerning the need for and ad-
dition of a full-time alcoholism counse-
lor for the Impaired Physicians Pro-
gram.
(2) Statement of the Problem . . . Ap-
proved the following recommendation:
That the Board of Trustees endorses the
Statement of the Problem as an official docu-
ment of the Impaired Physicians Program.
Noted that a copy of the full statement
is available upon request.
Old Business . . .
(1) Future Physician Supply in New Jer-
sey . . . Noted that according to cor-
respondence received from Donald B.
Louria, M.D., New Jersey will suffer
from the doctor glut by 1990.
(2) Special Committee on Long-Range
Planning and Development . . . Indicated
that the Board would like to develop
guidelines for the running and support-
ing of candidates seeking election or ap-
pointment to AMA office.
New Business . . .
(1) Denial of Payment to Surgical Assis-
tants in Hospitals Having a Surgical Resi-
dency Program . . . Received cor-
respondence from a Monmouth County
member objecting to a provision under
Medicare which stipulates that no pay-
ment may be made for the services of
assistants at surgery furnished in a teach-
ing hospital which has a training pro-
gram related to the medical specialty re-
quired for the surgical procedure and
has a resident available to perform the
service. Noted that James E.D. Gardam,
M.D., Vice-President of Medical Ser-
vices, Governmental Health Programs
Office of Prudential, suggested that
where exceptional medical circum-
stances exist, the case will be reviewed
on an individual basis.
(2) Preferred Provider Health Care Act
of 1983 . . . Reviewed AMA comments
on HR 2956, a bill that would preempt
state laws regarding Preferred Provider
Organizations (PPOs).
(3) Urgi-Centers . . . Will obtain infor-
mation from Ohio, Tennessee, and Ken-
tucky where legislation was enacted to
regulate and control the development of
urgi-centers and to require that these
centers be subjected to the certification
of need process.
President’s Column
Alexander D. Kovacs, M.D.
As I write this, the outlook for the
country as a whole is brighter than it has
been in some time. The future looks
good, but it does not look quite so rosy
for physicians. We appear to be at the
beginning of a decline. Most of us have
yet to notice any real change in our prac-
tices or our lifestyles but change is in the
air.
Will the changes result in better medi-
cal care? Recent statistics released by the
federal government would indicate we
are doing well now. The average life ex-
pectancy in the United States is the high-
est it ever has been. A baby born in 1982
can expect to live, on the average, to the
age of 75. Our infant mortality rate is
at its lowest. With a system this good,
why would anyone want to tinker with
it? You know the old saying, “If it isn’t
broke, don’t fix it!"
In one sense, the system is broke or
at least is going broke. Government
doomsayers tell us that we no longer can
afford all this good care. They still want
it to be good — they just do not want it
expensive. Health care costs represent
10.5 percent of the gross national prod-
uct, and government, big business, and
the unions are screaming. Because of the
cost and because of public perception,
unsupported by fact, that medical care
VOL. 81— NUMBER 1— JANUARY 1984
69
is not as good as it used to be, we are
in a state of flux. Rapid changes are
taking place and our futures will bear
only a faint resemblance to our past.
At the first White House Conference
on Aging, in the 1960s, the principle that
access to medical care was a right for all
citizens was first articulated; the means
for such access was created through
Medicare and Medicaid.
In the 1960s, unions were at the peak
of their power. They demanded and re-
ceived fringe benefits, most notably
health insurance coverage. Big business
thought it was money well spent even if
the demand was for first dollar coverage.
A second problem became apparent
quickly. With money for access to medi-
cal care, the demand was created for
more doctors. American medical schools
were built quickly and immigration
regulations were eased to permit foreign
medical graduates to fill the perceived
shortage.
We had the money and the doctors.
A combination like that leads to an in-
crease in technology and our golden age
was underway. We broke barriers in dis-
ease faster than ever before. We could
cure more people of more illness than at
any other time in history, and we did.
We did not do this alone. Hospitals
and nursing homes were built to accom-
modate our patients. Nurses, tech-
nicians, administrators, clerical help,
drug houses, and instrument manufac-
turers— an entire medical-industrial
complex — was built based on the new
ease of access and the money such access
provided. Health care has become the
nation’s largest industry with expen-
ditures of more than 300 billion dollars
per year. Its phenomenal growth rate of
15 percent annually makes it the nation’s
second largest employer.
Now, society and government are
alarmed at the size of their baby and its
insatiable appetite. Their answer is;
“The same level of care for less money.”
There are many proposals to reduce
costs and some of them have merit. That
a system should be as large as this
without some waste is not possible. The
big question is, “How much can you
tighten the belt before the patient says
ouch.” We physicians are going to say
ouch sooner than the patient.
Hospitals are readjusting faster than
we are. They are looking to the future
while we still bemoan the past. For-
profit hospitals are one of the fastest
growing segments of the industry. They
can bypass the sick and poor and con-
centrate on patients with good in-
surance. Nonprofit hospitals are begin-
ning to unbundle profitable services and
set up satellites. They have organized
themselves into cooperatives for the
purchase of services such as laundry and
food. They are hiring physicians to
provide outpatient care formerly avail-
able only in a doctor’s private office.
They are hiring brains in the form of
public relations experts to market their
product.
Insurance carriers also are adjusting.
Third-party payers are compiling lists of
preferred providers, i.e. doctors willing
to provide services for a negotiated fee.
They also are cutting down on first
dollar coverage.
Big business is renegotiating contracts
to include givebacks. The unions, caught
between shrinking memberships and
economic distress, are accomodating
themselves to the new reality.
What are we doing? First of all, we are
trying to get our members to understand
that a problem exists. At the same time,
we are trying to adapt our own swollen
ranks to the new rules of the game.
Competition? We must form partner-
ships between medical staffs and hospi-
tals for market development. Cost con-
tainment? We must try to encourage
such measures where the request for ser-
vice originates — with the patient. We
must discourage first dollar coverage
and encourage individual responsibility.
Public health? We must assume active
roles in promoting healthy lifestyles, i.e.
less junk food, no smoking, a reduction
in alcoholic consumption leading to ac-
cidents, and reduction of air, water, and
earth pollution.
There is a new era wherein neither the
prevention of death from epidemics nor
the correction of physiologically
measurable abnormalities will be the ob-
jective. The new central objective of
health care will be the maintenance or
improvement of individual patient func-
tioning in the patient’s normal environ-
ment while he/she performs usual ac-
tivities.
If we are to survive, we must do it by
working together for the common good.
None of us are going to get everything
we want. We will have to make some
concessions. We will have to accept that
the majority of doctors no longer will be
in the solo private practice of medicine.
We will have to stretch to accommodate
the younger physician, the salaried
physician, and the preferred provider.
We must realize that we cannot allow
our profession to be fragmented. We
physicians must stand together in one
united organization with the muscle to
negotiate and to fight for all members.
We must be active politically if we are
to have an impact on our futures.
The lessons of history are there for us
to learn. We ignore them at our peril.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
The Hospital Corporation of America
(HCA) has completed its first year as
interim manager of the day-to-day oper-
ations of University Hospital, having es-
tablished a foundation for pursuing
critical short- and long-term hospital ob-
jectives. The hospital management com-
pany has recruited new leadership, re-
aligned the hospital’s organizational
structure, furthered management train-
ing, and decentralized functions to in-
crease efficiency and effectiveness and to
maximize the hospital’s full potential as
a primary care facility serving Newark
and as a major teaching and referral
center serving all of New Jersey.
At a recent staff retreat attended by
officials of UMDNJ and HCA, several
hospital needs were re-emphasized.
Among them were the need for auto-
mated information systems (computers)
to store and transmit patient infor-
mation and records and new high-tech-
nology equipment necessary to the hos-
pital’s role as a regional state referral
center for many tertiary care services.
Participants in the retreat also reaf-
firmed commitments to furthering the
hospital’s “centers of excellence” in
areas such as cancer research and treat-
ment, the handling of traumatic injury,
and the care of high-risk maternity pa-
tients and newborns.
The contractural arrangement be-
tween UMDNJ and HCA is a three-year
agreement and only an interim step in
the overall plan for managing the hospi-
tal. During HCA’s tenure, the UMDNJ
Board of Trustees will continue to dis-
cuss the eventual structure for the most
efficient and effective governance of the
hospital.
UMDNJ and the St. George’s Univer-
sity School of Medicine reached a rental
agreement which enabled up to 190 stu- I
dents of the Grenada-based medical pro-
gram to pursue a course in gross
anatomy by using the facilities of
UM DNJ-Rutgers Medical School,
Piscataway. The agreement, effective
November 9, was to continue for no
longer than eight weeks. St. George’s
officials plan to re-establish the medical
school on Grenada or another off-shore
site by early in 1984. St. George’s Uni- :
versity faculty and students used a newly
70
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
[constructed space as a gross anatomy
^laboratory at the medical school. A
schedule was established under which
UMDNJ provided the laboratory space
for several hours Monday through Sat-
urday. A lecture hall also was made
available weekday evenings. St.
George's University provided its own
[ faculty and staff, its own cadavers, and
all necessary educational supplies. Its
students were not considered students of
UMDNJ, but were subject to all rules
and regulations of the UMDNJ-Rutgers
Medical School. The program and rental
was developed with the concurrence and
approval of the New Jersey Board of
Medical Examiners.
Victims of mild hypertension can re-
ceive free treatment through the Hyper-
tension Intervention Trial (HIT), a pro-
gram based on UMDNJ's Newark cam-
pus and designed to prove that these
people can maintain health without
drugs. The program, funded by a
$700,000 grant from the National In-
stitutes of Health's Heart, Lung, and
Blood Institute, concentrates on diet and
stress reduction.
Norman Lasser, M.D., associate
professor of medicine at UMDNJ-New
Jersey Medical School, and Norman
Hymowitz, Ph.D., clinical associate
professor of psychiatry, codirect the pro-
gram. Earlier both led the national
MRFIT program's New Jersey Medical
School center. The staff includes 20
nutritionists, psychologists, and other
health professionals.
A pioneering health care program for
diabetics, designed to reduce the debili-
tating disorders' often associated with
the disease, is underway at the Newark
campus of UMDNJ. The new am-
bulatory care program, which offers the
use of a 24-hour insulin pump, focuses
on an intensification of insulin therapy
coupled with the daily self-monitoring of
glucose levels of the eyes, kidneys, and
nerves. The UMDNJ program is admit-
ting diabetics who are 18 or older and
insulin-dependent. In addition to the in-
sulin and monitoring components, each
patient receives comprehensive educa-
tion on the disease, including proper
nutrition, exercise, and other health-
enhancing information. All patients will
receive continuous followup care for the
duration of the program, expected to be
at least three years.
According to Margo Cohen, M.D.,
program director and chief of en-
docrinology at UMDNJ-New Jersey
Medical School, patients are taught to
test their blood sugar levels; if needed,
they increase their insulin by adding in-
jections or using the pumping device.
Called the “Intensive Ambulatory
Treatment of Insulin-Requiring Dia-
betes,” and sponsored by a grant from
the Hunterdon Health Fund, the pro-
gram is modeled after a project being
run by the National Institutes of Health
at a number of medical centers across
the country.
MSNJ Auxiliary
Gale Wayman,
President
The start of a new year finds your
Auxiliary continuing to work hard in
many areas. With our members serving
on 14 councils or committees of the
Medical Society and reporting to our
Executive Board, we are trying to better
serve MSNJ by becoming better
educated.
Our legislative chairman, Mrs. Frank
Campo, and JEMPAC chairman, Mrs.
Frank Romano, Sr., have been doing an
outstanding job in keeping the member-
ship aware of what is happening with
medical legislation. Our members are
kept abreast of “legislative alerts” and
are asked to write their legislators. We
are aware of the problems with PPOs
and DRGs and by educating our mem-
bers on these and other problems facing
medicine, we are able to speak upon is-
sues that affect our hardworking spouses
who many times do not have the time
to defend and protect themselves. We
are asking our members to become in-
volved in the political process because
their involvement can make a difference.
AMNJ Report
Paul J. Hirsch, M.D.
President
The membership of the Academy of
Medicine of New Jersey continues to
grow, as it has over the last several years.
Nevertheless, the Board of Trustees re-
mains interested in encouraging new ap-
plicants for membership. At the recent
meeting of the Board, the membership
committee was directed to review our
procedures for new applicants, with a
view towards streamlining. For example,
now it is required that each applicant
provides three sponsors. It is proposed
that two, or perhaps even one sponsor,
would be sufficient. At the same time,
the Board wishes to maintain an ap-
propriate screening procedure. Dr. Ben-
jamin Rush, chairman of the member-
ship committee, will review these poli-
cies with his committee.
Dr. Alfred Alessi, chairman of the
education committee, recently reported
to the Board about a new interactive
computerized education technique. This
program currently is in use by other
medical organizations, and has been
demonstrated at an AMA educational
meeting. Dr. Alessi has arranged for this
program to be demonstrated at the next
meeting of the AMNJ Board of
Trustees. The aducation committee has
been invited to attend this meeting.
J. Richard Goldstein, M.D., Com-
missioner of Health of New Jersey was
the guest at the October “First Wednes-
day at the Academy” meeting. Dr.
Goldstein spent 1 Vi hours in an intensive
question-and-answer session. These
small luncheon meetings are open to all
members of the Academy of Medicine
and their spouses. The sessions are in-
tended to provide the opportunity for
free discussion in an informal setting. A
representative of the State Board of
Medical Examiners was the guest at the
November meeting.
At the January meeting of the Board
of Trustees, the Board decided upon the
recipients of the Edward J. Ill Award,
and of the Citizen's Award. The recipi-
ents of these awards will be formally
honored at the annual Academy dinner
on May 23, 1984.
New Members
The Journal would like to welcome the
following members to the Medical So-
ciety of New Jersey:
Atlantic County
Lawrence Blacher, M.D., Northfield
Raymond S. Schreyer, M.D., Pomona
Stephen H. Uretsky, M.D., Linwood
Bergen County
John T. Andronaco, M.D., Hackensack
Robert M. Bernstein, M.D., Englewood
Robert B. Ein, M.D., Westwood
Bernard Gardner, M.D., Hackensack
Donald H. Kutner, M.D., Saddle Brook
Murray H. Rothman, M.D., Rutherford
Geoffrey W. Tobias, M.D., Englewood
Burlington County
James Q. Atkinson, III, M.D., Medford
Max Burger, M.D., Medford
Joseph DeLaurentis, M.D., Mount Laurel
Jeffrey J. Kutscher, M.D., Moorestown
Mylappan Selvaraj, M.D., Browns Mills
Bruce W. Wulfsberg, M.D.
Cape May County
Warren F. MacDonald, Jr., M.D.,Cape May
Court House
Bruce R. Noll, M.D., Cape May Court
House
Essex County
RenatoC. Miguel, M.D., Paramus
Fanya Munits, M.D., Maplewood
Myles I. Rosenthal, M.D., New Providence
Lewis P. Stolman, M.D., Livingston
VOL. 81— NUMBER 1— JANUARY 1984
71
Gloucester County
Saroja Nadig, M.D., Woodbury
Hudson County
Ignacio A. Chiong, M.D., Union City
Mercer County
Robert B. Berger, M.D., Princeton
Steven R. Levine, M.D., Princeton
Frank P. Schinco, M.D., Trenton
Middlesex County
Pablo Bencosme, M.D, Perth Amboy
Anthony J. Chiaramida, M.D., Perth Amboy
Sheela Choubey, M.D, Piscataway
Nancy E. Gary, M.D., Piscataway
Betty L. Hammond, M.D., New Brunswick
Edward D. Harris, M.D., New Brunswick
Stuart M. Hochron, M.D., Iselin
Robert H. Rathauser, M.D., North
Brunswick
Stanley E. Rich, M.D., Manalapan
Joseph P. Romano, M.D., Rahway
Kenneth D. Steiner, M.D., Woodbridge
Lawrence T. Taft, M.D., New Brunswick
Monmouth County
Gabor Barabas, M.D., Long Branch
John B. Checton, M.D, Long Branch
Paul E. Dedick, M.D., Red Bank
Danilo R Espineli, M.D., Howell
Michael H. Flashburg, M.D., Asbury Park
Suresh C. Giri, M.D , Freehold
Jennifer L. Harper, M.D., Neptune
Michael D. Karoly, M.D., Red Bank
Amos Katz, M.D., Freehold
William 1. Kohlberg, M.D., Freehold
Randall S. Krakauer, M.D., Freehold
Mary L. Krisza, M.D., West End
Alvin H. Morgenstern, M.D., Freehold
Joseph T. Nitti, M.D., Brielle
Charles B. Peeples, M.D., Long Branch
Arthur H. Phair, M.D., Red Bank
Vijayalaxmi Varadarajan, M D., Red Bank
Morris County
Hiliary C. Brynildsen, M.D., Denville
Peter J. Brynildsen, Denville
Arthur R. Israel, M.D., Morristown
Barry K. Levin, M.D., Morris Plains
Lawrence M. Skolnick, M.D., Morristown
Andrew N. Stolzar, M.D., Dover
Passaic County
Ralph E. Caprio, M.D., Clifton
Steven R. Isaacson, M.D., Clifton
Deanna Z. Macek, M.D., Riverdale
Arnold H. Slyper, M.D., Paterson
Lawrence D. Weinstein, M.D., Pompton
Union County
Marvin J. Blumenfrucht, M.D., Elizabeth
Calvin G. Constandis, M.D., Cranford
Thomas F. Crompton, M.D., Elizabeth
Brian Donnelly, M.D , Summit
Richard L. Eichel, M.D., Elizabeth
Ralph E. Farinella, M.D., Union
Steven L. Halpern, M.D., Summit
Michael S. Lux, M.D., Summit
Donna D. Mahlstedt, M.D., Warren
Richard A. Marfuggi, M.D., Elizabeth
Erenio Mejias, M.D., Elizabeth
Kantilal Patel, M.D., Newark
Vito A. Petrozzino, M.D., Union
Adam J. Rowen, M.D., Elizabeth
Lome B. Sheren, M.D., Summit
Donald R. Sweeney, M.D., Summit
Richard W. Tai, M.D., Union
Stuart Waldstreicher, M.D., Summit
Warren County
Eduardo C. Lomibao, M.D., Phillipsburg
Physicians Seeking
Location in New Jersey
The following physicians have written to the
Executive Offices of MSNJ seeking infor-
mation on possible opportunities for practice in
New Jersey. The information listed below has
been supplied by the physician. If you are
interested in any further information concern-
ing these physicians, we suggest you make in-
quiries directly to them.
ANESTHESIOLOGY— Jan Charles Hor-
row, M.D., 131 Pond Brook Rd., Chestnut
Hill, MA 02167. Pennsylvania 1977. Board
certified. Group, academia, HMO. Avail-
able.
CARDIOLOGY — Aubrey Orrin Lewis,
M.D., 200 Carman Ave., Apt. 2 1 - F, East
Meadow, NY 11554. SUNY-Syracuse
1979. Also, general internal medicine.
Board certified (IM). Solo, partnership,
group, academia (cardiology). Available
July 1984.
Ltc. Gary P. Schwartz, M.D., USAF, 8
Lodge Dr., Rockville, MD 20850. SUNY-
Upstate 1968. Board certified. Single
specialty, multispecialty group, partner-
ship. Available September 1984.
FAMILY MEDICINE— Jaime F. Lara,
M.D., 6045 Palisade Ave., West New
York, NJ 07093. Seville (Spain) 1979.
Board eligible. Partnership or institutional-
ly based. Available.
David Neidorf, M.D., 1701 Taxville Rd.,
Apt. 7A, York, PA 17404, SUNY-Stony
Brook 1981. Board certified. Group, part-
nership, HMO. Available August 1984.
GASTROENTEROLOGY — Albert M
Harary, M.D., 2121 N. Bayshore Dr., Apt.
1001, Miami, FL 33137. Columbia 1978.
Also, general internal medicine. Board
certified (IM). Group, partnership, solo.
Available July 1984.
P. Kothanda Raman, M.D., 9 Lake Ave.,
Apt. 5A, East Brunswick, NJ 08816.
Stanley Medical College (India) 1977.
Board eligible (IM). Also internal medi-
cine. Partnership, group, solo. Available
July 1984.
INTERNAL MEDICINE — Harold J. Brown,
M.D., 260 Eggerts Rd., Lawrenceville, NJ
08648. UMDNJ 1982. Primary care clinic,
HMO, group, partnership. Available July
1985.
Elliott Friedman, M.D., 25 Penny La., Bal-
timore, MD 21209. SUNY-Syracuse 1978.
Subspecialty, endocrinology. Board
certified (IM); board eligible (endo-
crinology). Group or partnership (both
specialties). Available July 1984.
Lee W. Hoffer, M.D., 1017 East 80th St.,
Brooklyn, NY 11236. Rome (Italy) 1980.
Solo, partnership, group. Available.
Arvind Mehta, M.D., 805 1 N. Hanover St.,
Anaheim, CA 92861. Seth G.S. Medical
College (India) 1975. Also, nephrology.
Board eligible. Solo, group, associate.
Available.
P. Kothanda Raman, M.D., 9 Lake Ave.,
Apt. 5A, East Brunswick, NJ 0881; 1
Stanley Medical College (India) 197
Board eligible. Also, gastroenterolog
Partnership, group, solo. Available Ju
1984.
Patricia M. Romano, M.D., 1077 Riv
Rd., N608, Edgewater, NJ 07020. Cornci
University Medical College 1979. Als
pulmonary. Board certified. Group. Ava
able July 1984.
Laurence M. Silverstein, M.D., 500 Avi
G, #7, Redondo Beach, CA 90277. Albe !
Einstein 1979. Board certified. Availabl j
Yi-po Wu, M.D., 32 Hapgood Wa
Shrewsbury, MA 01545. National Taiwa
University Medical College 1972. Boar J
eligible. Group or partnership.
NEPHROLOGY — Arvind Mehta, M.D
805 i N. Hanover St., Anaheim, CA 92861
Seth G.S. Medical College (India) 1 975
Also, internal medicine. Board eligible
Solo, group, partnership. Available.
NEUROLOGY — Elizabeth Kamenar, M.D.
12701 Shaker Blvd., Apt. 410, Cleveland
OH 44120. Ohio State 1975. Board eligible
Group, partnership, academia. Availabli
July 1984.
Robert P. Rubens, M.D., 105 Ward St.
Apt. 204, Seattle, WA 98109. UMDNJ
New Jersey Medical School 1980. Boarc :
eligible. Available July 1984.
OBSTETRICS/GYNECOLOGY— Alan M
Askinas, M.D., 1309 Carrollton, Apt. 321,
Metairie, LA 70005. Illinois 1980. Board |
eligible. Group, partnership, solo, part
academia. Available July 1984.
Joseph Booker, Jr., M.D., 2500 Milvia St.,
Apt. 228, Berkeley, CA 94704. University
of California-San Francisco 1973. Partner-
ship, group, solo. Available.
Wook Chung, M.D., 2212 Watterworth
Dr., Kalamazoo, MI 49008. Catholic
Medical College (Korea) 1967. Board
certified. Solo, group, partnership. Avail-
able.
Iris E. Dominy, M.D., 108 Pinegate Circle,
Apt. 2, Chapel Hill, NC 27514. Albany
1978. Board eligible. Partnership or group
in metropolitan area. Available July 1984.
Angela McVey, M.D., 3191 Agate St.,
Philadelphia, PA 19134. Bucharest Medical
School (Rumania) 1949. Board eligible.
Group, partnership, hospital, academia.
Available.
OPHTHALMOLOGY — Steven R. Davis,
M.D., 1000 Lakeview Rd., Clearwater, FL
33516. University of Alabama 1975. Board
certified. Solo or association. Available.
Andrew Gewirtz, M.D., 519 Beach 133 St., |
Belle Harbor, NY 11694. Chicago 1978.
Board eligible. Board certified (pediatrics).
Group or partnership. Available July 1984.
PAT HOLOGY — Mark A. Grathwhol, M.D.,
2510 West Tremont Ct., Richmond, VA
23225. NYU 1980. Group. Available July
1984.
PEDIATRICS — Jonathon J. Evans, M.D.,
1800 Calvin Ct., #6, Iowa City, IO 52240.
Univ. of California-San Diego 1981. Board
eligible. Group or HMO. Available July
1984.
72
! ME JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Howard Mintz, M.D., 60 Presidential
Plaza, Apt. 308, Syracuse, NY 13202. Pitts-
burgh 1981. Board eligible. Group or part-
nership. Available July 1984.
PSYCHIATRY— Eric M. Levin, M.D., 43
West 8th St., Media, PA 19063. La Faculte
Libre de Medicine (Spain) 1980. Board
eligible. Group, institutionally based,
CMH outpatient. Available July 1984.
PULMONARY DISEASES— James Kohan,
M.D., 19 Highmanor Dr., Henrietta, NY
14467. Virginia 1979. Also, general internal
medicine. Board certified (IM). Group,
partnership, solo, institutional. Available
July 1984.
Patricia M. Romano, M.D., 1077 River
Rd., N608, Edgewater, NJ 07020. Cornell
University Medical College 1979. Also,
internal medicine. Board certified (IM).
Group. Available July 1984.
RADIOLOGY/NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon St.,
Apt. 3B, Brookline, MA 02146. Boston
1976. Board certified. Group or partner-
ship. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond Brook
Rd., Chestnut Hill, MA 02167. Med Col-
lege of Pennsylvania 1980. Board eligible.
Group, HMO, academia. Available.
RHEUMATOLOGY— Richard Furie, M.D.,
435 E. 70th St., Apt. 8-F, New York, NY
10021. Cornell 1979. Also, general internal
medicine. Board certified (IM). Group,
partnership, solo. Available July 1984.
SURGERY, GENERAL— Ramon J Gomez,
M.D., 40-71 Gleane St., Elmhurst, NY
1 1373. University of the East (Philippines)
1978. Group or hospital-based emergency
medicine practice. Available.
Ravinder Jagpal, M.D., 3408 Balboa La.,
Apt. 33, Columbia, MO 65201. Rutgers
1981. Also cardiothoracic surgery. Board
certified (general surgery); board eligible
(cardiothoracic surgery). Group. Available
July 1984.
SURGERY, ORTHOPEDIC— Jeffrey H
Charen, M.D., 155 Lexington St., Apt. 15,
Auburndale, MA 02166. Rochester 1978.
Board eligible. Group, partnership, solo
(central or northern NJ preferred). Avail-
able January 1984.
Salvatore Inserra, M.D., 1847 79th St.,
Brooklyn, NY 11214. NYU 1979. Board
eligible. Group, partnership, solo. Avail-
able July 1984.
Richard Lebovicz, M.D., 415 Grand St.,
New York, NY 10002. SUNY-Downstate
1979. Group or partnership. Available July
1984.
Oscar A. Reicher, M.D., 71 Brookwood
Ter., Nashville, TN 37205. Pittsburgh
1979. Solo or group. Available July 1984.
UROLOGY — Joseph G. Colonna, M.D.,
1234 Van Voorhis Rd., Apt. C-6, Morgan-
town, WV 26505. Guadalajara (Mexico)
1977. Board eligible. Group or partnership.
Available October 1984.
Barlow S. Lynch, M.D., 5145 Linda Lou
Dr., Carmichael, CA 95608. SUNY-Buf-
falo 1977. Board eligible. Partnership,
group, solo, academia. Available July 1984.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500
Immediate Release
LIPO-NICIN® /250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily
AVAILABLE: Bottles of 100, 500
LIPO-NICIN®/100 mg.
Each blue tablet contains
Nicotinic Acid 100 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug.
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
( BRolMTfc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 1*®
VOL. 81— NUMBER 1— JANUARY 1984
Housing Application
218th ANNUAL MEETING
THE MEDICAL SOCIETY OF
NEW JERSEY
MAY 3-6, 1984
Single
Twin
Suites
Resorts International
(headquarters hotel)
$80.00
$80.00
$171 /$250
Harrah’s Marina Hotel Casino
$75.00
$75.00
World International Hotel/Motel
$58.00
$58.00
Lafayette Motor Inn
$58.00
$58.00
Rates subject to 12% state and local taxes; tax subject to change.
i
All hotel reservations for the 218th Annual Meeting of MSNJ will be handled by the Atlantic City Convention
Bureau. Please send your housing application with your 1st, 2nd, and 3rd choices directly to the Bureau, 16 Central
Pier, Atlantic City, NJ 084.01. All Delegates and Members are urged to make their hotel reservations early. Blocks
of rooms will be available at Resorts International (headquarters hotel), Lafayette Motor Inn, World International
Hotel/Motel, and Harrah's Marina Hotel Casino. The cut-off date for reservations will be April 6, 1984. Reservations
cannot be guaranteed after this date. No Saturday arrivals please. All registrants will be charged for three nights:
Thursday, Friday, and Saturday, May 3, 4, and 5, 1984.
MAIL THIS APPLICATION DIRECTLY TO THE ATLANTIC CITY CONVENTION BUREAU
16 Central Pier
Atlantic City, NJ 08401
Please list 1st, 2nd, and 3rd choices; confirmation will come directly from hotel.
1st Choice 2nd Choice
3rd Choice
Accommodations desired: □ Single □ Twin □ Suite Parlor & T Bedroom
□ Suite Parlor & 2 Bedrooms
Name
Address
City— State Zip
Phone ___
Wil1 arrive — Time Will depart Time
date
Check if Official Delegate County
74
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
V/IEDICAL PHILATELY
rhe Path to Modern Medicine
JOSEPH H. KLER, M.D., New Brunswick*
ABDOMINAL SURGERY
Theodor Billroth (1829-1894) was
ijjborn in Ruegen and obtained his medi-
cal degree from the University of Berlin
in 1852. In 1859, he was appointed
professor of surgery at the University of
Zurich, and from 1867 until his death he
held a similar position at the University
of Vienna. During the Franco-Prussian
War (1870-1871), he served as surgeon
in the military hospitals at Weissenberg
and Mannheim.
In 1871, Billroth successfully per-
formed the most extensive resection of
the pharynx to date (pharynx, larynx,
epiglottis, and thyroid). Also, he in-
troduced a successful gastrorrhaphy for
the cure of gastric fistula. Billroth per-
formed the first successful gastrectomy
for cancer of the pylorus on January 29,
1881. Malignant lymphoma (Billroth’s
disease) received his surgical appraisal as
! a destructive lesion with nodal recur-
rence. His contributions to medical
literature included, General Surgical
Pathology and Therapeutics, which went
through 1 1 editions and was translated
into many languages.
Considered one of the foremost sur-
geons of his time, Billroth was an
authority on histology, pathology, and
military surgery. A man of genial per-
sonality and strong artistic bent, he was
a lifelong friend of Johannes Brahms. In
1887, Billroth was given a seat in the
upper house of Parliament of Austria-
Billroth
Austria, 1937
Hungary, a distinction rarely conferred
on a member of the medical profession.
He had the respect and love of all Vien-
na. He is considered the founder of mod-
ern abdominal surgery.
DIGESTION AND CONDITIONED
REFLEXES
Ivan Pavlov (1849-1936) was born in
Ruazan, Russia, the son of a priest. He
studied at St. Petersburg University and
received his doctorate in 1883. He then
studied with Heidenhain in Breslau and
with Ludwig in Leipzig.
Pavlov returned to St. Petersburg and
became one of the greatest physiologists
of modern times. He became interested
in the processes of gastric digestion and
painstakingly worked out the details of
the role of the autonomic nervous sys-
tem. For this, Pavlov received the Nobel
Prize in 1904.
However, Pavlov’s most outstanding
work was on “conditioned reflexes,” a
physiological discovery of first rank that
has had a profound influence on physi-
ology and psychology.
r
Pavlov
Argentina, 1949
*It is with regret that we state this will be the
last column on medical philately. Dr. Kler
died on November 22, 1983.
VOL. 81— NUMBER 1— JANUARY 1984
75
Ajml-Septcmiher 1984
# 312 lues. Eves, 4-7 p.m.
Medicine
Board
TUITION:
$795
Accreditation:
63 AMA Category 1 credit hours.
63 AAFP credit hours.
63 ACEP credit hours.
MJ
For New York metropolitan area physicians: Twenty one weekly 3-hour
sessions spread over a 21 week period to prepare for the written portion
(Part I ) of the Emergency Medicine Board Examination, plus on a
limited first-come basis two, 2 -hour ("1 on 1") patient management
encounters for each registrant that simulates and prepares candidates
for the oral portion ( Part II) of the Board Examinations.
Information available on #315 EMERGENCY MEDICINE, June 18-22, 1984,
Monday-Friday
FOR Ft IRTHER INFORMATION: NYl Post-Graduate Medical School
550 First Avenue. New York, NY 10016 (212) 340-5295 (24 Hour Service)
iS
LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY.
WEDNESDAY, FEBRUARY 1, 1984
CARDIOMYOPATHY
MODERATOR: BERNARD L. SEGAL, M.D.
3:00 CASE PRESENTATION Edward Catherwood, M.D
3:30 THE CLINICAL, ECHOCARDIOGRAPHIC, VENTRICULOGRAPHIC
DIAGNOSIS OF HYPERTROPHIC CARDIOMYOPATHY Gary S Mintz M D
4:00 THE REST AND EXERCISE ELECTROCARDIOGRAM AND HOLTER
MONITORING IN PATIENTS WITH HYPERTROPHIC
CARDIOMYOPATHY
4:30 MEDICAL AND SURGICAL MANAGEMENT/RISK
AND BENEFIT
5:00 NEW ADVANCES IN CORONARY ANGIOPLASTY
5:30 PANEL DISCUSSION
A- Ham id Hakki, M.D.
Morris N. Kotler, M.D.
Demetrios Kim bin's, M.D.
LECTURE HALL A 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
9 NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
**W!NE & CHEESE SERVED FOLLOWING CONFERENCE**
76
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CME CALENDAR
This list is compiled through the cooperation
of the Committee on Medical Education of the
Medical Society of New Jersey, the Academy
of Medicine of New Jersey, the New Jersey
Chapter of the American Academy of Family
Physicians, and the Office of Continuing Medi-
cal Education of the University of Medicine
and Dentistry. For information on accredita-
tion, please contact the sponsoring organiza-
tions), indicated by italics — last line of each
item.
ANESTHESIOLOGY
Feb.
11 Clinical Anesthesia 1984
8 a. m. -3:50 p.m. — UMDNJ-New Jersey
Medical School, Newark
( UMDNJ )
Mar.
9 25th Postgraduate Anesthesia Seminar
10 8 a.m. — Hyatt, Cherry Hill
1 1 ( NJ State Society of A neslhesiologists
and A MNJ )
CARDIOLOGY
Feb.
16 Pathophysiology and Management of
Angina Pectoris
5-6:30 p.m. — Somerset Medical Center,
Somerville
(Somerset Medical Center )
Mar.
7 Noninvasive Testing in Cardiovascular
Disease
9-1 1 a.m. — Middlesex General Hospital,
New Brunswick
( Middlesex General Hospital and A M NJ)
7 Cardiology
14 3-6 p.m. — Overlook Hospital, Summit
21 ( Overlook Hospital and A M NJ)
20 Current Therapy of Acute Myocardial
Infarction
12 noon — St. Mary’s Hospital, Orange
(AMNJ)
MEDICINE
Feb.
1 Endocrinology Series-Medical Grand
Rounds
1 1:30 a.m. — VA Medical Center, East
Orange
2 9:30 a.m. — Newark Beth Israel Medical
Center, Newark
3 11:30 a.m. — UMDNJ-University
Hospital, Newark
(Endocrinology Section, AMNJ)
1 Endocrine Conference
8 3:30-5 p.m. — Rotates between Newark
15 Beth Israel Medical Center, University
22 Hospital, United Hospitals Medical
29 Center, Newark, and VA Medical
Center, East Orange
(Endocrinology Section, AMNJ)
1 Newer Insulins
8 Congenital Pulmonary Anomalies
I -2:30 p.m. — Christ Hospital, Jersey
City
(Christ Hospital)
1 Diagnosis and Treatment of Incontinence
in Geriatric Patients
1 :30 p.m. — Essex County Hospital
Center, Cedar Grove
(Essex County Hospital Center)
1 CDS Prescribing Practices
I I a.m. -12 noon — Morristown
Memorial Hospital
(AMNJ)
1 Gastroenterology
15 Pulmonary
22 Pulmonary
3-6 p.m. — Overlook Hospital, Summit
(Overlook Hospital and AMNJ)
1 Lung Cancer
8 Breast Cancer
15 Sickle Cell Anemia
22 Chronic Lymphocytic Leukemia
29 Metabolic Renal Stone Disease
8- 9 a.m. — Alexian Brothers Hospital,
Elizabeth
(Alexian Brothers Hospital and AMNJ)
1 Hodgkins and Non-Hodgkins Lymphoma
8 Urological Cancer
15 Hematologic Emergencies
22 Colon Cancer
29 Burn Assessment and Emergency
Treatment
9- 10 a.m. — Alexian Brothers Hospital,
Elizabeth
(Alexian Brothers Hospital and A MNJ)
2 The Current Status of Antiviral
Chemotherapy
1 1 a.m. -12:30 p.m. — St. Joseph’s
Hospital and Medical Center, Paterson
(St. Joseph 's Hospital and Medical
Center)
3 Renal Conference in Nephrology
17 4-5 p.m. — UMDNJ-University Hospital,
Newark
(Nephrology Society of NJ, Nephrology
Section, and AMNJ)
7 Geratrics-Medication Prescribing
Practices
21 Hypertension-Malignant
11-12 noon — Greystone Park Psychiatric
Hospital, Greystone Park
( Greystone Park Psychiatric Hospital)
9 Diagnosis and Treatment of Multiple
Sclerosis
1 1 a.m. — St. Joseph’s Hospital and
Medical Center, Paterson
(UMDNJ and St. Joseph ’s Hospital)
15 Rutgers Dermatological Conference
6- 9 p.m. — Rutgers Community Health
Plan, 57 U.S. Hwy. 1, New Brunswick
(UMDNJ and AMNJ)
17 Management of Portal Hypertension
8- 9:30 a.m. — Overlook Hospital,
Summit
(Overlook Hospital)
21 Nephrotoxicity-1984: An Update
4-5 p.m. — Academic Health Service
Center, New Brunswick
(UMDNJ)
21 Prevention and Treatment of Decubitus
Ulcers
12 noon — St. Mary’s Hospital, Orange
(St. Mary's Hospital)
21 Sodium Homeostasis in Liver Disease
7- 8 p.m. — Ramada Inn, Clark
(Nephrology Society of New Jersey)
22 Pulmonary Function Tests and
Emphysema
10:30-12 noon — St. Mary’s Hospital,
Passaic
(St. Mary's Hospital)
22 Renal Hypertension or HPN Secondary
to Kidney Disease
1 :00 to 2:30 p.m. — VA Medical Center,
Lyons
( Veterans A dministration Medical
Center)
29 Evaluation and Treatment of
Occupational and Environmental Lung
Disease
9- 1 1 a.m. — Middlesex General-
University Hospital, New Brunswick
( Middlesex General-University Hospital)
29 Ophthalmology Associated with Systemic
Diseases
10:30-12 noon — St. Mary’s Hospital,
Passaic
(St. Mary 's Hospital)
Mar.
1 Medical Grand Rounds
9:30 a.m. — Newark Beth Israel
Medical Ctr.
( Endocrinology Section, AMNJ)
1 Effects of Stress on Disease
15 Heart Disease, Lipoproteins, and
Nutritional Counseling
1 1 a.m. — St. Joseph’s Hospital and
Medical Center, Paterson
(St. Joseph 's Hospital and UMDNJ)
2 Medical Grand Rounds
1 1 :30 a.m. — University Hospital,
Newark
(Endocrinology Section, A M NJ)
2 Renal Conferences in Nephrology
16 4-5 p.m. — UMDNJ-University Hospital,
Newark
( Nephrology Society of NJ and
Nephrology Section, A MNJ)
6 Nutrition Support — Middle Age and the
VOL. 81— NUMBER 1— JANUARY 1984
77
WE NEED YOUR ASSISTANCE!
The Treatment Loan Fund of
the Impaired Physicians Program
Our impaired colleagues often are financially impaired in addition
to their major impairment. MSNJ has set up a loan fund to assist these
physicians with low interest loans in meeting the costs of treatment
and/or family support during their time away from their practice in
treatment.
The Board of Trustees of MSNJ has authorized this ad to solicit
voluntary contributions from our membership to this fund We have
begun solicitation of the New Jersey pharmaceutical houses and to date
we have received contributions from Warner Lambert; Sandoz; Merck;
American Home Products; and Squibb.
A common question in soliciting contributions from outside source
is "What are the doctors doing?" Your assistance will aid our impaired
colleagues and improve our outside returns.
Please send you contributions to: Impaired Physicians Program
Treatment Loan Fund, Medical Society of New Jersey, 2 Princess
Road, Lawrenceville, NJ 08648.
my I medkal cbntel Post- G raduate
1 Medical School
January
Internal Medicine Board Review, Wednes-
1/4-6/20
days, 4-7 PM
March
12-16
Managing Clinical Problems in the Elderly
(Cerromar Beach Hotel/Puerto Rico)
19-23
Seminar in Advanced Rheumatology
26-30
Anesthesiology: Comprehensive Review III
April
26-28
Update in Clinical Dermatology
Information:
Mary Ann Giammarino, NYU Post-Graduate
Medical School, 550 First Avenue, New York, NY 10016 (212)
340-5295.
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
January 27-29, 1984 and again the weekend of March 23-25,
1984 at the Barbizon Plaza Hotel, New York City. Co-sponsored
by the International College of Acupuncture & Electro-Thera-
peutics, its official journal (published by Pergamon Press) the
Heart Disease Research Foundation and the Neuroscience
Dept, of Long Island College Hospital, Pharamcology Dept, of
The Chicago Medical School. Also eligible for AMA/CME credit.
For information, contact Y. Omura, M.D., ScD., 800 Riverside
Drive (8-1), NYC 10032. Tel: (212) 781-6262 or (212) WA8-0658,
or Saul Heller, M.D., Tel: (212) 838-7514.
CONTRACEPTION TODAY
Improving the Results — Reducing the Concerns
March 31 -April 1, 1984
SCANTICON-PRINCETON CONFERENCE CENTER
PRINCETON, NEW JERSEY
Topics Include: Improving Contraceptive Utilization •
Managing Common Complaints • Risks • Detection of
Contraceptive Failure • Legal Aspects of Providing
Contraception.
Inquiries: Patricia Reid, UMDNJ-Rutgers Medical
School, Box 101, Piscataway, NJ 08854 (201) 463-4707
CHRONIC DISORDERS IN PEDIATRICS:
Naw Approaches to Old Problems
March 21, 22, 1984
Central Nervous System Trauma
Chronic Respiratory Disorders
Kinesthetic Disorders
Birth Defects
The Madison Hotel
Convent Station, New Jersey
Sponsored by:
CHILDREN'S SPECIALIZED HOSPITAL
New Providence Road
Mountainside, New Jersey 07091
for more information call:
Sallie Comey
Education Coordinator
(201) 233-3720
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
For the Investigation of
Problems of Human Infertility
The Foundation provides a complete
diagnostic and consultation service for in-
fertile couples. Investigations are con-
ducted by well-known specialists in con-
junction with consultants in the various
fields of medicine related to infertility.
The Foundation is supported by an in-
house modern laboratory equipped to do
most tests required for diagnosis and
treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
78
HE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Elderly
1 1 a.m.-12 noon — Greystone Park
Psychiatric Hospital
(A MNJ)
7 Medical Grand Rounds
1 1 : 30 a.m. — VA Medical Ctr.,
East Orange
( Endocrinology Section. AMNJ)
7 Hypertension
1:30 p.m. — Essex County Hospital Ctr.,
Cedar Grove
(AMNJ)
7 Angina
21 Obstructive Uropathy
1-2:30 p.m. — Christ Hospital,
Jersey City
( Christ Hospital and A M NJ )
7 Endocrine Conferences
14 3:30-5 p.m. — Rotates between Newark
21 Beth Israel Medical Ctr., UMDNJ-
28 University Hospital, Newark, VA
Medical Ctr., East Orange, and United
Hospitals Medical Ctr., Newark
( Endocrinology Section. A M NJ)
8 Pain Therapy
2 p.m. — John E. Runnells Hospital of
Union County, Berkeley Heights
(AMNJ)
13 Diet and Cancer
22 Detection and Diagnosis
29 Principles of Patient Management
4- 6 p.m. — Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
15 Current Approaches to Irritable Bowel
Syndrome
5- 6:30 p.m. — Somerset Medical Ctr.,
Somerville
(Somerset Medical Center and A M NJ )
20 Emergency Care — Cardiac Drug
Overdose
I I a.m. -12 noon — Greystone Park
Psychiatric Hospital
(AMNJ)
20 Hypertension
1 :30-2:30 p.m. — Essex County Hospital,
Cedar Grove
(A MNJ)
20 Regional Nephrology Conferences
4-5 p.m. — Academic Health Science Ctr.
(UMDNJ-Rutgers Medical School and
A MNJ )
21 Dermatological Conference
6-9 p.m. — Rutgers Community Health
Plan, 57 U.S. Hwy. 1, New Brunswick
( UMDNJ-Rutgers Medical School and
AMNJ)
21 Significance and Treatment of Common
Abnormalities in Serum Electrolytes
and/or Acid-Base Balance
28 Antibiotic and Antiviral Agents in an
Office Practice
9-1 1 a.m. — Middlesex General Hospital,
New Brunswick
( Middlesex General Hospital and A MNJ)
28 Extended Spectrum Penicillin and
Cephalosporins
10:30 a.m. -12 noon — St. Mary's
Hospital, Passaic
(St. Mary 's Hospital and A M NJ)
28 Implications of Clinical Trials on
Management of Mild Hypertension
1- 2:30 p.m. — VA Medical Center, Lyons
( VA Medical Center and A MNJ)
28 Dermatology
3-6 p.m. — Overlook Hospital, Summit
(Overlook Hospital and A MNJ)
NEUROLOGY/PSYCHIATRY
Feb.
1 Psychopharmacology
2- 3 p.m. — Ancora Psychiatric Hospital,
Hammonton
(Ancora Psychiatric Hospital and A MNJ)
2 Benzodiazepines in the 1980s
16 Suicide Assessment
12 noon-1 p.m. — Carrier Foundation,
Belle Mead
( Carrier Foundation and A MNJ)
9 The New Pathogens
12 noon-1 p.m. — Carrier Foundation,
Belle Mead
( Carrier Foundation and A MNJ)
15 Group Therapy
29 2-3 p.m. — Ancora Psychiatric Hospital,
Hammonton
( Ancora Psychiatric Hospital and AMNJ)
16 Spirit, Psyche, Religion, and
Psychopathology
12 noon-4:30 p.m. — Carrier Foundation,
Belle Mead
( Carrier Foundation and A MNJ)
29 Neurology
3- 6 p.m. — Overlook Hospital, Summit
(Overlook Hospital and A MNJ)
Mar.
1 Pharmacotherapeutic Agents in the
Management of Borderline-Personality
Disorders
8 Advances in Neuroleptic Medication
15 Alone — Yearning for Companionship
12 noon-1 p.m. — Carrier Foundation,
Belle Mead
( Carrier Foundation and A MNJ)
6 Is There a Devil?
8: 1 5-10:30 p.m. — 39 Crescent Ave.,
Passaic
( Essex Psychiatric Seminar and A MNJ)
218th Annual Meeting
May 2-6, 1984
Resorts International
Atlantic City, New Jersey
Daily Schedule
Wednesday, May 2, 1984
3:30 p.m. — Board of Trustees' Meeting
7:00 p.m. — Officers' Cocktail Reception followed by Dinner
Thursday, May 3, 1984
9:00 a.m. — Registration Opens
2:00 p.m. — House of Delegates
4:00 p.m. — Reference Committees (Three Reference Committee
Meetings)
Friday, May 4, 1984
7:30 a.m.— Registration Opens
9:00 a.m. — House of Delegates (election)
9:00 a.m. — Message Center, and Scientific, Informational, and Insurance
Exhibits Open
12:00 noon — Golden Merit Award Ceremony followed by Reception
2:30 p.m. — Reference Committees (Three Reference Committee
Meetings)
5:00 p.m. — JEMPAC Political Forum
5:45 p.m. — JEMPAC Wine & Cheese Reception
Saturday, May 5, 1984
8:00 a.m. — Registration Opens
9:00 a.m. — Message Center, and Scientific, Informational, and Insurance
Exhibits Open
9:00 a.m. — Scientific Sessions
12:00 noon — Luncheons
1 :00 p.m. — Scientific Sessions
6:30 p.m. — Inaugural Reception followed by Inaugural Dinner
Sunday, May 6, 1984
6:30 a.m. — County Society Breakfast Caucuses
8:00 a.m. — Registration Opens
9:00 a.m. — Message Center, and Scientific, Informational, and Insurance
Exhibits Open
9:00 a.m. — House of Delegates
3:00 p.m. — Board of Trustees’ Meeting
VOL. 81— NUMBER I— JANUARY 1984
79
7 Group Therapy
21 2-3 p.m.— Ancora Psychiatric Hospital,
Hammonton
(A ncora Psychiatric Hospital and AMNJ )
14 Anxiety and Neurosis
9-1 1 a.m. — Middlesex General Hospital,
New Brunswick
f Middlesex General Hospital and A M NJ )
15 Aspects of Anorexia Nervosa
8- 10 p.m. — Hackensack Hospital
(NJ Psychoanalytic Society and A M NJ)
19 Principles of Child Psychotherapy
8:30-10:30 p.m.— Office of Dr. Deutsch,
301 Broad St., Englewood
(NJ Psychoanalytic Society and AMNJ)
21 Tardive Dyskinesia and Other Movement
Disorders
9 a.m. -4:45 p.m. — Carrier Foundation,
Belle Mead
( Carrier Foundation and A M NJ)
OBSTETRICS/GYNECOLOGY
Feb.
1 Amenorrhea
9- 11 a.m. — Middlesex General-
University Hospital, New Brunswick
( Middlesex General-University Hospital)
1 Laparoscopy, Colposcopy, Infertility
10:30-12 noon — St. Mary's Hospital,
Passaic
(St. Mary's Hospital)
2 Fetal Visualization of Prenatal Diagnosis
9:00 a.m. — Freehold Area Hospital,
Freehold
(Freehold Area Hospital)
Mar.
31 Contraception Today
9 a.m. -5 p.m. — Princeton Scanticon
Conference Ctr., Princeton
( UM DNJ-Rutgers Medical School and
A MNJ)
PATHOLOGY
Feb.
2 Macrophages and Their Relations to
Neoplasia
9 Natural Killer Cells
16 Cell-Mediated Immunity and Regulatory
Cells
23 Tumor Protective and Facilitating
Antigens
4-6 p.m. — Institute for Medical
Research, Camden
(Institute for Medical Research)
8 Pathology Grand Rounds
10:30 a.m. -12 noon — St. Mary’s
Hospital, Passaic
(St. Mary's Hospital)
Mar.
1 Biology of Immune Complexes in Cancer
8 Epidemiology of Cancer: An Overview
4-6 p.m. — Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
14 Pathology Grand Rounds
10:30 a.m. -12 noon — St. Mary’s
Hospital, Passaic
( St. Mary 's Hospital and A MNJ)
80
21 Pathology Slide Seminar/New Procedure
Update
7- 9 p.m.— Hyatt House, Cherry Hill
(South Jersey Pathology Society and
A MNJ)
PEDIATRICS
Mar.
1 The Mouth and Teeth in Pediatric
Practice
9 a.m. — Freehold Area Hospital
(A MNJ)
19 Pediatric Lecture Series
12 noon-1 p.m.— The Mountainside
Hospital, Montclair
(The Mountainside Hospital and AMNJ)
21 Chronic Disorders in Pediatrics:
22 New Approaches to Old Problems
8 a.m. -4 p.m. — Madison Hotel, Convent
Station
(Children's Specialized Hospital)
23 Diagnosis and Management of the
Various Forms of Rickets
8- 9:30 a.m. — Overlook Hospital,
Summit
( Overlook Hospital and A M NJ)
PSYCHIATRY
Feb.
3 Psychiatric Aspects Concerning the
Prevention of Nuclear War
8:30-10:30 p.m. — The Atrium West,
West Orange
( New Jersey Psychiatric Association)
6 Anorexia in a Professional Woman
8:15-10:30 p.m. — Office of Rita
Newman, M.D., 543 Park St.,
Upper Montclair
(Essex Psychiatric Seminar)
8 Muscle Weakness-Approach to Diagnosis
and Treatment
22 Fits and Faints
9- 11 a.m. — Middlesex General-
University Hospital, New Brunswick
(Middlesex General-University Hospital)
15 Sleep Onset Insomnia: Assessment and
Clinical Management
1-2:30 p.m. — Christ Hospital Jersey City
(Christ Hospital)
15 Treatment of the Agitated Elderly Patient
1 :00 to 2:30 p.m. — VA Medical Center,
Lyons
( Veterans A dministration Medical
Center)
20 Principles of Child Psychotherapy
8:30-10:30 p.m. — Office of Lawrence
Deutsch, M.D., Englewood
( New Jersey Psychoanalytic Society)
RADIOLOGY
Feb.
8 Radiology
3-6 p.m. — Overlook Hospital, Summit
( Overlook Hospital and A MNJ)
16 Radiology Meeting
7:30-10 p.m. — St. Barnabas Medical
Center, Livingston
(Radiological Society of NJ. Radiology
Section, and A MNJ)
Mar
16
21
Radiology Meeting
7:30-10 p.m. — St. Barnabas Medical
Center, Livingston
( Radiological Society of NJ and
Radiological Section, A MNJ)
Dinner Meeting
6:30 p.m. — The Manor, West Orange
(Radiotherapy Section, AMNJ)
SURGERY
Feb.
1
8
15
22
29
15
Surgical Departmental Conferences
8:30-10 a.m. — Medical Education Bldg.
Rutgers Medical School,
New Brunswick
( UMDNJ )
Thyroid, Parathyroid Surgery
10:30-12 noon — St. Mary’s Hospital,
Passiac
(St. Mary's Hospital)
Mar.
7
14
21
28
Use of Appropriate Antibiotics in Surgery
10:30 a.m. -12 noon — St. Mary’s
Hospital, Passaic
(St. Mary 's Hospital and A MNJ)
Diagnosis and Surgical Management of
Esophageal Reflux and Hiatus Hernia
10:30 a.m. -12 noon — St. Mary’s
Hospital, Passaic
(St. Mary 's Hospital and A M NJ)
Surgical Departmental Conference
8:30-10 a.m. — Rutgers Medical School,
Medical Education Bldg.
( UMDNJ-Rutgers Medical School)
SURGICAL SPECIALTIES
Feb.
2
9
16
23
15
Vascular Surgical Rounds
4-5 p.m. — Rutgers Medical School,
New Brunswick
(UMDNJ)
When and Why To Replace Which Joint-
An Update
9-11 a.m. — Middlesex General-
University Hospital, New Brunswick
(Middlesex General-University Hospital)
Mar.
1 Vascular Surgical Rounds
8 4-5 p.m. — Rutgers Medical School,
15 Medical Education Bldg.
22 (UMDNJ-Rutgers Medical School)
29
6 Surgical Management of Benign and
Malignant Disease of the Breast
7:30 p.m. — Burdette Tomlin Memorial
Hospital, Cape May Court House
(AMNJ)
MISCELLANEOUS
Mar.
Clinicolegal Correspondence Course
Seif-Instruction-Contact Medical Inter-
Insurance Exchange
( Medical Inter-Insurance Exchange of NJ
and A MNJ)
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ETTERS TO THE EDITOR
/ocal Cord Paralysis
October 17, 1983
Dear Dr. Knosnick:
I am writing in reference to a case
r report in the October 1983 issue of The
Journal. A case of vocal cord paralysis
n a benign histological disease certainly
is interesting and worth reporting.
[Fibrosing mediastinitis certainly is rare
'■and interesting enough as well.
Although the article is entitled, “Tem-
porary Vocal Cord Paralysis,” there is
no evidence that the vocal cord indeed
truly recovered. The fact that the patient
was free of hoarseness seven weeks later
probably meant that the opposite vocal
cord compensated for the left vocal cord
paralysis or the left vocal cord migrated
to the midline. Those of us who do or
who are familiar with thyroid surgery
are quite familiar with this happening.
A simple mirror indirect laryngoscopy
postoperatively may have been done and
inadvertently unreported. This clinical
!
VOL. 81— NUMBER 1— JANUARY 1984
finding would have been more in keep-
ing with the title of the case report,
(signed) Lawrence J. Pizzo, M.D.
Phimosis: A Cause
of Renal Failure
October 25, 1983
Dear Doctor Krosnick:
My congratulations to Joel W. Rosen-
berg, M.D., for his excellent article in
the October 1983 issue of The Journal
entitled, “Phimosis: A Cause of Renal
Failure.” His emphasis on the plethora
of articles in the lay and pediatric litera-
ture objecting to circumcision is a point
well taken and may lead to increased
susceptibility, as mentioned, to venereal
disease, malignancy, local inflammatory
conditions, paraphimosis, urinary reten-
tion, and recurrent verruca of the fore-
skin.
These conditions occur not only in the
young, but also in those of advanced
years. I would like to mention a black
man, age 102 years, who was admitted
to Ancora State Hospital a few years ago
with a diagnosis of chronic brain syn-
drome. He was seen in consultation be-
cause of incontinence during the day and
at night. He was extremely lethargic and
had a markedly elevated BUN. Examin-
ation of the penis revealed a markedly
redundant foreskin with a pinpoint
opening. He would urinate into the fore-
skin and then would drip urine constant-
ly. He had a history of working on his
farm in Salem County the previous sum-
mer and had married three times; each
of his wives had died. Circumcision was
performed, with return of the BUN to
normal and complete clearing of his sen-
sorium.
In selected cases where there is dif-
ficulty retracting the foreskin easily, cir-
cumcision is mandatory. In proper
hands, circumcision is a relatively simple
operation with lasting beneficial results,
(signed) Stanley J. Okulicz, M.D.
OBITUARIES
Dr. George E. Barbour
George Edgar Barbour, M.D., a phy-
sician at Somerset Medical Center,
Somerville, for over 50 years, died on
October 28, 1983. Born in 1903, Dr.
Barbour earned his medical degree at the
University of Pennsylvania Medical
School in 1928. A surgeon, Dr. Barbour
was a member of our Somerset County
component and of the American Medi-
cal Association. Dr. Barbour was the
recipient of MSNJ's Golden Merit
Award for his years of service to the
medical community.
Dr. Herman H. Goldstein
A retired member of our Union Coun-
ty component, Herman Harold Gold-
stein, M.D., died on September 30, 1983.
Born in 1902, Dr. Goldstein received his
medical degree from Yale University
School of Medicine, Connecticut, in
1927. A urologist, Dr. Goldstein was af-
filiated with Newark Beth Israel Medical
Center, St. Elizabeth Hospital, and
Alexian Brothers Hospital, both in
Elizabeth. A member of the American
Medical Association, Dr. Goldstein was
a Fellow of the American College of
Surgeons, a Fellow of the International
College of Surgeons, and a Diplomate of
the American Board of Urology.
Dr. Louis F. Marrella
Louis Frank Marrella, M.D., former
director of the NYSA-ILA Medical
Center, Hoboken, died on October 3,
1983. Born in 191 1, Dr. Marrella earned
his medical degree from Loyola Medical
School, Illinois, in 1940. Dr. Marrella
was a member of our Hudson County
component and of the American Medi-
cal Association and was a Fellow of the
American Academy of Family Practice.
During his career, Dr. Marrella was af-
filiated with Jersey City Medical Center
and Christ Hospital, Jersey City.
Dr. Martin M. Meehan
At the grand age of 87, Martin Mat-
thew Meehan, M.D., died on October
27, 1983. Dr. Meehan received his medi-
cal degree from the University of Ver-
mont College of Medicine in 1925. Dur-
ing his lengthy career. Dr. Meehan was
affiliated with St. Mary Hospital,
Passaic. Dr. Meehan was a recipient of
MSNJ’s Golden Merit Award for 50
years of service to his community. A
retired member of our Essex County
component. Dr. Meehan was a member
of the American Medical Association.
Dr. Alexander E. Schefrin
Alexander Eugene Schefrin, M.D.,
died on October 16, 1983. Born in
1904, Dr. Schefrin received his medical
degree from Long Island College of
Medicine, New York, in 1928. A pedia-
trician, Dr. Schefrin was affiliated with
General Hospital and Beth Israel Hospi-
tal, both in Passaic. Dr. Schefrin was a
member of our Passaic County compo-
nent and of the American Medical As-
sociation; he was a Diplomate of the
American Board of Pediatrics and a Fel-
low of the American Academy of Pedi-
atrics. In 1978, Dr. Schefrin was the re-
cipient of MSNJ's Golden Merit Award
for 50 years of medical service.
Dr. Eugene W.R. Sims
At the age of 62, Eugene W. Rock-
feller Sims, M.D., died on October 26,
1983. Dr. Sims earned his medical
degree at Meharry Medical College,
Tennessee, in 1945, and then established
a family practice in East Orange in 1947.
Dr. Sims served as federal aviation ad-
ministration examiner and as medical di-
rector for the Essex County Department
of Corrections; also, he was medical di-
rector of the Armed Forces Examining
Center in Newark. Dr. Sims was a mem-
ber of our Essex County component and
of the American Medical Association.
Dr. Sims was the first air surgeon for the
New Jersey Air National Guard. He re-
ceived the Col. Vance H. Marchbanks
Award of the National Medical Associa-
tion and the Air National Guard Meri-
torious Service Award for his contribu-
tions to military medicine.
Dr. Joseph G. Varhol
A member of our Passaic County
component, Joseph Gregory Varhol,
M.D., died on October 1, 1983. Born in
1917, Dr. Varhol received his medical
degree from the University of Maryland
School of Medicine in 1943. During his
career, Dr. Varhol was affiliated with
General Hospital, Passaic, where he was
the president of its medical staff in 1967
and director of the department of
anesthesia. Dr. Varhol was a member of
the American Medical Association and
a Fellow of the American College of
Anesthesiologists.
Dr. Don B. Weems, Sr.
At the age of 81, Don Bright Weems,
Sr., M.D., died on October 15, 1983,
after a long illness. Dr. Weems earned
his medical degree at Jefferson Medical
College, Pennsylvania, in 1930. A mem-
ber of our Gloucester County compo-
nent, Dr. Weems was affiliated with
Underwood Memorial Hospital, Wood-
bury. Dr. Weems was a family practi-
tioner; he was a member of the Ameri-
can Medical Association. In 1981, Dr.
Weems received MSNJ’s Golden Merit
Award for 50 years of medical service to
his community.
Dr. William L. Weintraub
At the age of 82, William Louis Wein-
traub, M.D. died on September 30,
1983. Dr. Weintraub earned his medical
degree at Bellevue Hospital Medical
College, New York, in 1923. During his
lengthy career, Dr. Weintraub was af-
filiated with Barnert Memorial Hospital
Center, Paterson, Chilton Memorial
Hospital, Pompton Plains, St. Joseph’s
Hospital and Medical Center, Paterson,
and two Passaic Hospitals, Saint Mary’s
Hospital and Beth Israel Hospital. In
1973, Weintraub was the recipient of
MSNJ's Golden Merit Award for 50
years of service as a physician.
82
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
BOOK REVIEWS
Clinical Gastroenterology.
A Problem-Oriented
Approach
Sidney Cohen, M.D. New York, NY,
John Wiley & Sons, Inc., 1983. Pp. 464.
($25)
I commend the editor for a good and
useful book. The authors are recognized
experts and many already have appeared
in large disease-oriented standard text-
books. This book is designed for pri-
mary care physicians and general in-,
ternists who frequently need practical
help with gastrointestinal (GI) patients.
The book is organized by specific
clinical problems that may be seen daily
by practicing physicians. The editor
found that some of the topics would be
better handled as specific disease en-
tities, with clinical problems discussed in
the text. He succeeded in keeping the
inevitable duplication to an admirable
minimum. There are 18 chapters
grouped in four parts; i.e. main presen-
tations of GI disease, specific GI con-
dition, GI cancer, and hepatobiliary dis-
ease.
There are very few illustrations, but
the tables and algorithms are very useful
as is the index. I missed the pictures, but
appreciated the resultant economies.
The book succeeds as an aid to the prac-
ticing generalist and will be read with
profit by many gastroenterologists as
well. Norman Riegel, M.D.
Current Surgical Diagnosis
& Treatment, Sixth Edition
Lawrence W. Way, M.D., (ed). Los
Altos, CA, Lange Medical Publications,
1983. Pp. 1221. Illustrated. ($28)
This new book is a most fitting memo-
rial edition to Dr. J. Engelbert Dunphy,
formerly professor of surgery emeritus.
University of.California School of Medi-
cine, San Francisco, who was associated
with its concept.
The material is up to date; the book
is revised biennially. The text is very
complete, stressing the broad surgical
diagnostic and therapeutic aspects of
surgery.
Art work and photography are excel-
lent and helpful. Indexing is sensible and
accurate. Well-selected references are
provided throughout.
Subjects included in the text include
major areas such as anesthesiology,
wound healing, cancer chemotherapy,
transplantation, and diseases of individ-
ual organs.
It is a pleasure to recommend the text
to all associated with the care of surgical
patients, be they medical students, clini-
cians, or academicians. The editors, con-
tributors, and publishers certainly have
provided, as planned, concise, up-to-
date information about surgery.
The text is printed on good paper and
with clear type. Its cover is soft. Attest-
ing to the value of the material in the
book is the fact that it is published in
many foreign languages.
Robert K. Spiro, M.D.
Heart, Multiple Imaging
Procedures
Florencio A. Hipona, M.D., (ed). New
York, NY, Grune & Stratton, 1983. Pp.
241.
This book is one of a series in imaging
procedures of various systems. Well-
known radiologists contributed chapters
covering the various imaging diagnostic
modalities used to study the heart. There
are discussions on cineangiocardiog-
raphy, echocardiography, nuclear
cardiology, and other new diagnostic
modalities.
The chapters on axial cineangiog-
raphy, congenital heart disease, and cor-
onary artery disease are very well done
and will be of great interest to those
physicians doing cardioangiog-
raphy. Two-dimensional echocardiogra-
phy also is well discussed and in great
detail and is worth the price of this
book.
However, the chapters on dynamic
chest roentgenography (kymography),
99mtechnetiurn pyrophosphate myo-
cardial infarct scanning, and cardiac
computed tomography practically could
have been omitted. There is no dis-
cussion at all about the great potential
of nuclear magnetic resonance in cardiac
imaging.
There are enough topics that will
interest cardiac radiologists and
cardiologists to make this a worthwhile
book to peruse.
Heart, Multiple Imaging Procedures is
not, however, a book that is the defini-
tive work in the field.
Sidney Ketyer, M.D.
Manual of Clinical
Gastroenterology
Gail L. Bongiovanni, M.D. New York,
NY, McGraw-Hill Book Company, 1983.
Pp. 581. ($15.95)
This is one of a series of manuals
about clinical medicine designed for an
audience of medical trainees, clinical
clerks, and house officers.
The subject, gastroenterology, is sub-
divided into 19 chapters, each written in
a terse outline form and an appendix
about signs and symptoms of GI disease.
The first two chapters are generalized,
about pain and GI bleeding, and
together with the appendix would be
useful to a young clinician, especially at
night when confronted by a critically ill
patient.
Each topic is covered in only two or
three pages or less and a recent bibli-
ography refers the interested reader to
more information. I found the index too
short, but the trainee probably will use
the table of contents as a guide. The
experienced specialist will disagree at
numerous minor points, but will agree
with almost all of the presentations. I
especially liked the tables and
algorithms.
The authors are all fellows or assistant
professors at Columbia and Harvard;
however, the material is all so basic that
VOL. 81— NUMBER 1— JANUARY 1984
83
regionalism does not intrude and these
are the words of the front liners about
up-to-date use and interpretation of tests
and current treatments. For those in
training and for many generalists, this
manual would be very useful for navi-
gation on a stormy night at the hospital.
Norman Riegel, M.D.
The Social Transformation
of American Medicine
Paul Starr. New York, NY, Basie Books,
Inc., 1982. Pp. 514. ($24.95)
The Social Transformation of Ameri-
can Medicine is a book that should be
read by every physician. In spite of its
harsh words and, at times, abrasiveness
toward doctors, it reveals how our pro-
fession attained its present status. Paul
Starr’s basic thesis seems to be that doc-
tors have created a sovereignty which is
beginning to erode through fragmenta-
tion into specialties, industrialization,
exploitation by corporations, and
capitulation to bureaucracy. Many facts
and figures are presented to support this
view. Statistics can be boring but, I as-
sure you, this book is not as dull as its
title. It more properly could be called a
bible of American medicine, and could
be divided into the historical books, a
hospital book, a public health book, a
book on medical economics, books on
health insurance, a book on medical
schools, a book on third parties, and a
book on competition.
The author is a sociologist and looks
at doctors through the eyes of a social
activist. More than once he brings out
that our cultural authority becomes con-
verted into economic power and politi-
cal influence. He speaks of the essence
of our achievement being the ability to
see social interests defined so as to con-
form with our own interests.
This book often is eloquent, with
many quotable passages. For example,
the dean who exclaimed, “It’s easier to
move a cemetery than to change a cur-
riculum.’’ It speaks of postwar America
as being “a society which believed it had
solved life’s most serious problems, ex-
cept what to do with one’s spare time.”
The author recalls Everett Hughes’s
definition of quacks as “practitioners
who continue to please their customers
but not their colleagues.” In two pages,
the book describes the three types of
medical benefits (indemnity, service, and
direct) better than the much-discussed
report “D” of the AMA's Council on
Medical Services distributed at the an-
nual meeting in June 1983.
No one involved in health care is
neglected: specialists (“The specialist
typically gives up those services offering
the lowest return and concentrates on
those offering the highest.” “Specialty
incomes vary directly with the per-
centage of work reimbursed by third
parties.”); pharmacologists (“Between
1900 and 1910, three changes enabled
the medical profession to wrest control
of the flow of pharmaceutical infor-
mation”); general practitioners (“Medi-
cine is so large now that a doctor doesn’t
feel confident unless he knows at least
one field extremely well, rather than a
little about all subjects”); physicians in
group practice (“Does it mean that the
family physician is being replaced by a
corporation?”); medical school
professors (“It is inconceivable that the
university would try to carry out a policy
contrary to the wishes of the department
chairmen of the medical school and
damned difficult for the hospital to carry
out a policy contrary to the wishes of the
chiefs”); entrepreneurs “(Who deprive
both private doctors and local voluntary
hospitals of their traditional auton- i
omy”); doctors in politics (“In the past,
decisions on health care delivery were
largely professional ones. Now the de-
cisions will be largely political”); hospi-
tal trustees (“Must increasingly exercise
the authority conveyed to them by law
to supervise their medical staffs.”); and
even those who wish to care for them-
selves (“Courts view the doctor-patient
relationship as a partnership in decision
making rather than a doctors’ mon-
opoly.”).
By the time you finish this book, your
intellectual wheels will be spinning, j
There is an adequate index and painstak-
ing notes.
The big questions asked by the author
(and to be answered in time) remain;
How do we as physicians retain our
autonomy and not lose control? How do
we handle the new forces which threaten
to reduce the sovereignty that private
doctors have long exercised over medical
care? In spite of feeling that “doctors
continue to hold strategic positions
through their established relations with
both patients and hospitals,” Paul Starr
still predicts a backward move of doc-
tors into institutional services, a forward
move by hospitals into ambulatory care,
and the creation of hybrid prepayment
plans by insurance companies.
It may be that the whole book is !
summed up quite well by a sentence in
the final paragraph: “Images of the fu-
ture are usually only caricatures of the
present.” If you want to face reality,
read this book!
John S. Madara, M.D.
84
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
INFORMATION FOR AUTHORS
The Journal, the official organ of the
Medical Society of New Jersey, is pub-
lished monthly under the direction of the
Committee on Publication. The goals of
The Journal are educational and in-
formational. All material published in
The Journal is copyrighted by the Medi-
cal Society of New Jersey.
CONTENT
The educational content of each issue
appears as scientific articles, based on
research, original concepts relative to
epidemiology of disease, and treatment
methodology; case reports based on un-
usual clinical experiences; review
articles; clinical notes, succinct items on
some aspect or new observation or tech-
nique of a case experience; and special
articles, which include evaluations, poli-
cy and position papers, and reviews of
nonscientific subjects. Other topics in-
clude commentary (critical narration);
medical history; therapeutic drug in-
formation; pediatric briefs; nutrition up-
date, and an opinion column. Editorials
are prepared by the Editor and by guest
contributors on timely and relevant sub-
jects; editorials are the responsibility of
the author. The Doctors’ Notebook sec-
tion contains organizational, informa-
tional, and administrative items from
MSNJ and from the community. Letters
to the Editor and book reviews are
welcome and will be published as space
permits. The principal aim in the prepa-
ration of contribution should be rel-
evance to diagnosis and treatment and
to education of patients and pro-
fessionals. Preference will be given to
professional authors from New Jersey
and to out-of-state lecturers who submit
a suitable manuscript based on a presen-
tation made in New Jersey.
ASSIGNMENT OF COPYRIGHT
In compliance with the Copyright Re-
vision Act of 1976 (effective January 1,
1978), a transmittal letter or a separate
statement accompanying material of-
fered to The Journal of the Medical
Society of New Jersey must contain the
following language and must be signed
by all authors;
“In consideration of The Journal of
the Medical Society of New Jersey tak-
ing action in reviewing and editing my
submission, the author(s) undersigned
hereby transfers, assigns, or otherwise
conveys all copyright ownership to the
Medical Society of New Jersey, in the
event that such work is published in The
Journal, MSNJ.”
SPECIFICATIONS
Submit two manuscripts that must be
typewritten and double-spaced on
8- 1 /2" by 11” paper. This material is for
the exclusive use of The Journal and will
not be published elsewhere except in
abstract form or with the consent of the
Committee on Publication. Statistical
methods used in articles should be iden-
tified. Acknowledgments will be made
only for specific preparation of an essen-
tial part of the manuscript.
Authors are asked to seek clarity,
accuracy, and originality; attention to
details of grammar, spelling, and typing
are important.
The title page should include the full
name, degrees, and affiliations of all
authors, and the name and address of
the author to whom reprint requests
should be sent.
The author should submit a 50-word
abstract to be used at the beginning of
the article.
Tables must be typewritten and
double-spaced on separate 8-1/2” by
11” sheets, with a title and number.
Symbols for units should be confined to
column headings, and abbreviations,
properly explained, should be kept to a
minimum.
Illustrations should be professional
quality, black-and-white glossy prints.
The name of the author, figure number,
and the top of the figure should be noted
on a label attached to the back of each
illustration. Where photographs of pa-
tients are used, the subjects should not
be identifiable or publication per-
mission, signed by the subject or respon-
sible person, must be included with the
photograph. Material taken from other
publications must give credit to the
source; written permission for republica-
tion from the original publisher must be
submitted. The cost of color photo-
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Generic names should be used with
proprietary names indicated parenthet-
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of the generic name. Proprietary names
of devices should be indicated by the
registration symbol — ®.
The summary of the article should not
exceed 250 words; it should contain only
essential facts.
References should not exceed 35 cita-
tions except in review articles, and
should be cited consecutively in the text
by numbers in parentheses at the end of
the sentence. The reference list should be
typewritten and double-spaced on sepa-
rate 8-1/2” by 11” sheets in the numer-
ical order in which they are first cited in
the text. The style of reference is that of
Index Medicus:
1. Goldwyn RM: Subcutaneous mas-
tectomy. J Med Soc NJ 74:1050-1052,
1977.
2. Dixon WJ, Massey FJ; Introduc-
tion to Statistical Analysis. New York,
NY, McGraw-Hill, 1969, Pp. 42-48.
PUBLICATION POLICY
Receipt of each manuscript will be
acknowledged and a copy delivered to
the Editor who refers the paper to one or
more members of the Editorial Board.
The final decision is reserved for the
Editor. No direct contact between the
reviewers and the authors will be per-
mitted, but authors will be informed of
the reviewers’ comments. The publica-
tion lag for original articles may be six
months or more. Galley proofs will be
submitted to the author for correction of
typographical errors.
REPRINT ORDERS
Reprints may be ordered after the
author is notified that the article has
been selected for a specific issue of
JMSNJ. A check for the cost of reprints
including remake charge if order is re-
ceived after due date must accompany
the order.
COMMUNICATIONS
All communications should be sent to
the Editor, The Journal, MSNJ, 2 Prin-
cess Road, Lawrenceville, NJ 08648.
VOL. 81— NUMBER 1— JANUARY 1984
85
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CLASSIFIED ADVERTISEMENTS
ANESTHESIOLOGIST— Seeks position
Board certified, experienced anesthesiologist
seeks position in central or south Jersey.
Broad clinical experience in all phases of
anesthesiology. Small hospital preferred. Re-
sume and details on request. Reply to Main-
land Anesthesia, P.A., 52 East New York
Avenue, Somers Point, NJ 08244. Call (609)
927-7782.
GENERAL PRACTITIONER— Desires in-
dustrial, pharmaceutical or similar position.
Semi-retired, age 55. (201) 545-4339.
GENERAL SURGEON— Board certified,
wishes to join another surgeon or a group in
the area of Monmouth County or adjoining
counties. If interested please contact Dr.
Hasan (201) 972-1584.
INTERNIST — Available immediately, fel-
lowship in cardiology. Looking for associa-
tion to join a group or hospital based situ-
ation in Southern New Jersey, especially Bur-
lington and Camden counties. Write Box No.
41, JMSNJ.
OB/GYN— Available, UMDNJ Rutgers
trained, graduate with broad clinical ex-
perience in infertility, colposcopy, maternal-
fetal medicine and ambulatory services, seeks
private practice in Central-North New Jersey.
Write Box No. 59, JMSNJ.
OB/GYN — Available, UMDNJ trained,
UMDNJ graduate with broad clinical ex-
perience seeks to join private practice in Cen-
tral-North New Jersey or Manhattan. Speaks
fluent Spanish. Write Box No. 60, JMSNJ.
OPHTHALMOLOGIST — Desires partner-
ship or group. Board eligible July 1984, board
certified ped (1982), age 29. Available July
1984. Write Box No. 58, JMSNJ.
ORTHOPEDIC SURGEON— Desires as-
sociation with group or solo. Board eligible,
Albert Einstein 1978, Mt. Sinai (NY) or-
thopedic residency 1983. Presently in
Arthritis Total Joint Replacement Fellowship
at University of Colorado. Available July
1984. Berton Taffet, M.D., 1177 Race St.,
Denver, CO 80206. Phone (303) 320-6355.
PHYSICIAN — Semi-retired, 57 years old,
seeking part time or full time position. Prefer-
able, industrial clinic. Telephone (201)
224-5252.
NEEDED — Cardiologist/General internist.
Multi-specialty group. Southern New Jersey,
seeking a board certiHed /eligible cardiologist
and general internist. Send C.V. to Box No.
54, JMSNJ.
NEEDED— I nternist. Board certified or
eligible to join 10-man multi-specialty group
in suburban Morris County, NJ. Immediate
opening available for permanent position.
Send C.V. to Box No. 44, JMSNJ.
NEEDED — Internist/Cardiologist. To join 2
clinical cardiologists. Busy practice in South
Jersey community. 35 minutes from Philadel-
phia and Atlantic City. Respond with C.V.
to Box No. 45, JMSNJ.
NEEDED— I nternist. Board certified/eligi-
ble. Must have had training in cardiology,
gastroenterology and endoscopy for associa-
tion position in busy general practice North-
ern New Jersey suburban setting. Submit re-
sume to Box No. 56, JMSNJ.
NEEDED— I nternist. Board certified/eligible
to join former New Jersey internist now in
solo practice in Blue Ridge/Smokey Moun-
tain cosmopolitan community. Salary first
year plus all fringes, then partnership pro-
gression. Send CV to Box No. 57, JMSNJ.
NEEDED — OB/GYN. To join solo practice
in South Jersey shore area. Growing area, one
hour from Philadelphia. Write Box No. 42,
JMSNJ.
NEEDED — Associate. Pediatrician board
certified, seeks associate (board
certified/eligible) to join well established
practice. Excellent opportunity. Northern
New Jersey near New York City. Write Box
No. 40, JMSNJ.
NEEDED— Pri mary Care Physicians. Private
fee-for-servive practice in new, fully equipped
suburban offices. All personnel supplies, and
management services provided. This is an ex-
cellent opportunity for physicians with a
good "bedside" manner interested in develop-
ing a lucrative practice and still desiring time
for the pursuit of happiness. Reply to Neigh-
borhood Doctor Corporation, 901 Long
Beach Blvd., Ship Bottom, NJ 08008.
NEEDED — Radiologist. Part time, 2 morn-
ings per week. Ocean County. Prefer compe-
tent retired person. Write Box No. 62,
JMSNJ.
WANTED— Gh ost writer for Medical
Articles for publication. Write P.O. Box 61,
Livingston, NJ 07039.
PRACTICE/ALLERGIST— Certified or
board eligible for purchase of very desirable
Practice, child and adult. Central NJ Write
Box No. 47, JMSNJ.
FOR SALE — Practice, established, lucrative,
excellent location. Office fully equipped,
ready to take over. Exceptional opportunity
for young physician. Two family house, six
rooms and two baths. Available if required.
Jersey City. (201) 433-0743.
FOR SALE — Home/Office. Large beautiful
home with doctor's office in Summit. Seven
bedrooms, four full bathrooms, three powder
rooms, four fireplaces. Office at ground level,
completely furnished with large waiting
room, receptionist and bookkeeping area,
five large examining rooms. Separate en-
trance and exit. Twenty car parking area.
House and office have fire, smoke and bur-
glar alarms. Separate three-car carriage house
with four-room apartment (two bedrooms).
Swimming pool 22' x 46', close to two acres
beautifully landscaped. Five minutes from
Overlook Hospital Please write to Box No.
28, JMSNJ.
FOR SALE— Fa mily Practice or rent office
and equipment near a 550 bed teaching hospi-
tal in Monmouth County. Call after 6 P.M.
(201) 681-2566.
FOR SALE or RENT — Fully equipped and
furnished medical office building including
small medical practice. ECG, x-ray machines.
Therapeutic Ultrasound, Pulmonor. Good
location, Kearny, NJ. Call after 8 P.M. (201)
746-1709.
MEDICAL OFFICE — Half interest in medi-
cal office with rental income. Three private
rooms, internist equipment and furnishings.
Shared use of common areas. Central
Middlesex County location. Offered at
$60,000, financing available. Also available
for rent at $700. monthly including all util-
ities, equipment and furnishings. Write Box
No. 61, JMSNJ.
OFFICE SPACE FOR SALE— Roselle
Modern 2,400 square feet. 6 treatment rooms
and 4 consultation rooms. On-site parking.
Warinanco Medical Building. Phone (201)
687-0102.
OFFICE FOR RENT — Bergen County,
Ridgefield, NJ. 700 square feet. Call (201)
833-0117.
OFFICE SPACE — Edison. 1214 square feet,
8 rooms, bathroom, carpeted, near all high-
ways and hospitals. On-site parking, available
immediately. Dr. Bronstein (201) 738-8000.
OFFICE SPACE For Rent— 1300 square
feet. New building, 712 Amboy Avenue,
Edison. Ample parking, no steps. Near Perth
Amboy and JFK hospitals. Call (201)
442-4444.
OFFICE SPACE — Moorestown, NJ. Vic-
toria Medical Arts Building. Renting custom
medical offices in new building. Ideal for
radiologist, orthopedist, urologist, general
surgeon, industrial physician. Excellent lo-
cation and parking. Call (609) 235-2651.
MEDICAL OFFICE For Rent— G reat lo-
cation in resort center Vernon. Manager on
site, easy terms. (201) 764-3330 days, (201)
382-6284 nights and weekends.
OFFICE FOR SHARE — Berkeley Heights.
800 square feet in professional building.
Interested parties write to P.O. Box 1293,
Summit, NJ 07901.
OFFICE FOR SHARE— Highland Park. 900
square feet office space. Fully equipped, near
hospital. Minimal rent, $250. per month in-
cluding utility and equipment. For details call
(201) 545-2045.
SHARE OFFICE— Ridge wood, near Valley
Hospital. Prime medical space, new building.
Large parking lot, easily accessible, on main
road. Call (201) 652-6060.
VOL. 81— NUMBER 1— JANUARY 1984
87
Want to expand your practice?
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TAXES AND ACCOUNTING
AFFECT YOUR PROFITABILITY!
GEIN, CONNOLLY & SWJTAJ
Certified Public Accountants
Central New Jersey CPA Firm Providing Tax,
Accounting and Management Advisory Services
to the Medical Profession.
721 North Beers Street
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(201) 739-2020
FOR SALE: two ten percent interests in a New
Jersey Subchapter “S” equipment leasing corpor-
ation. Prefer New Jersey Physician with former or
current military affiliation. Write to Col John T.
Evans or Maj Edward K. Ernstrom at First National
Equipment Corporation, Ten Woodhill Road,
Towaco, New Jersey 07082. Tel 4:30 pm to 9:00
pm 201-263-5054.
A SPECIAL PRACTICE
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What makes it special? You’ll enjoy an excellent
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88
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Journal
of the Medical
Society of
New Jersey
FEBRUARY 1984
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OL. 81— NUMBER 2— FEBRUARY 1984
89
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1766
Officers and Trustees
President
Alexander D. Kovacs, M.D.
President-elect
Frank Y. Watson, M.D. (Es
First Vice President
Ralph J. Fioretti, M.D. (Ber
Second Vice President
Edward A. Schauer, M.D. (1
Immediate Past President
Howard D. Slobodien, M.D.
Secretary
Arthur Bernstein, M.D. (Esst
Treasurer
Trustees
Douglas M. Costabile, M.D., Chairman (\%4) (Union) .. Murray Hill
Frank Campo, M.D. (1984) (Mercer) Trenton
Harry M. Carnes, M.D. (1985) (Camden) Audubon
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
John J. Crosby, Jr., M.D. (1984) Jersey City
Palma E. Formica, M.D. (1984) (Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985) (Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
William Greifinger, M.D. (1984) (Essex) Belleville
John P. Kengeter, M.D. (1984) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Michael R. Ramundo, M.D. ( 1984) (Passaic) Clifton
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1984) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A. Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Albert F. Moriconi, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1984) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia, M.D., Chairman (1985) Spring Lake
Alfred A. Alessi, M.D. (1984) Hackensack
Frederick W. Durham, M.D. (1984) Haddonfield
Palma E. Formica, M.D. (1984) New Brunswick
Karl T. Franzoni, M.D. (1984) Trenton
John S. Madara, M.D. (1984) Salem
Henry J. Mineur, M.D. (1984) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Scotch Plains
Publication Committee
.. Glen Ridge
Paul J. Hirsch, M.D., Chairman
Rochelle Park
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
. Farmingdale
A. Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Metuchen
Leon G. Smith, M.D.
South Orange
La Verne Fioretti
.. Bridgewater
Editor
February 1984
Arthur Krosnick, M.D.
Managing Editor
Geraldine R. Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Stuart D. Cook, M.D. (Neurol)
Robert Dodelson, M.D. (Nephrol)
Wm. A. Dwyer, Jr., M.D. (Surg)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Arthur Goldfarb, M.D. (Allerg/Clin Immunol)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Joel D. Levinson, M.D. (Gastroenterol)
Henry R. Liss, M.D. (Neurosurg)
Geobel A. Marin, M.D. (Int Med/Gastroenterol)
Robby Meijer, M.D. (Plas Surg)
Christopher A. Papa, M.D. (Dermatol)
Victor Parsonnet, M.D. (Vase Surg)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F, Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A. Arthur Sugerman, M.D. (Psychiat)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except semimonthly
in July (13 issues), under direction of the Committee on Publication by the Medical Sncietv nf lsjo,,, i^r ^ x d ■
Road, Lawrenceville, NJ 08648. Primed in East Stroudsburg. PA by the Hughes Prmtin^ To L™ Pn"£S
Member s subscription ($10) is included in Society dues. Rates for nonmembers, $20; outside USA add^ 7^0° for postage
Single copies, $2. Address communications to The Journal MSNJ, 2 Princess Road Lawrenceville NT 08648
Second-class postage paid a, Trenton. NJ. and addit.onal entry office. CwritfWE'SfiM £§2$ ^NewJersey
90
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TAX PREPARATION AND PLANNING
Individual, Partnership, Corporate, Business, Estate
Services
Expert Services
Federal, Any State, Foreign Taxes of any type
All Year Service
Audit Representation
Tax Planning and Reduction
In Home or In Office Service
H. Michael Zukowski
(201) 945-8443
If your professional
liability insurance company
ran out of money, you could
find yourself very much . . .
Want to expand your practice?
we are
SPECIALISTS
in
PUBLIC RELATIONS
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for a confidential interview call —
(201) 531-7080
phyllis kessel associates
780 West Park Avenue, Oakhurst, N.J. 07755
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A professional service message from the
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Two Princess Road, Lawrenceville, NJ 08648
(609) 896-2404
‘ The Doctors * Company ”
OL. 81— NUMBER 2— FEBRUARY 1984
91
February 1984
Journal of
the Medical
Society of
America’s
First
Medical
Society
CON TENT S
94 MEMBERSHIP NEWSLETTER
99
105
105
106
107
110
PROFESSIONAL LIABILITY COMMENTARY
EDITORIALS
Blood Banks and AIDS
Sir Frederick G. Banting— The Artist
Baby Doe and the Prognosis Committee
HOSPITAL GOVERNING BOARDS
ARTICLES
Postmyocardial Infarction Rupture of the Ventricular Septum
S.K. Agarwal, M.D., J. Haft, M.D., J. Goldstein, M.D., Newark
1 13 The First Clinical Year of Medical School
H. Kranzler, M.D., K. Vitting, M.D., R.C. Reynolds, M.D., Piscataway
121 Is There an Indigenous Viral Flora in Man?
F.J. Michalski, Ph.D., Newark
125 May a Blood Bank Refuse Donations To Prevent the Spread of AIDS?
LG. Smith, M.D., R. Brennan, LL.D., B. McDonough, J.D., Newark
CASE REPORTS
131 Hydatid Disease of the Liver
M.A. Kessler, M.D., S. Ketyer, M.D., J.V. Cholankeril, M.D., J. Cenizal, M.D., Elize
135 Fine-Needle Aspiration in Metastatic Malignant Melanoma
D. Rothman, M.D., Y. Olaizola, M.D., J. Baker, C.T., Red Bank
MEDICAL HISTORY AND ART
138 The Art of Banting
A. Krosnick, M.D., Lawrenceville
IMPAIRED PHYSICIANS PROGRAM
140 Advocacy
D.l. Canavan, M.D., Lawrenceville
DOCTORS’ NOTEBOOK
143 Trustees’ Minutes: December 16, 1983
144 President’s Column, Alexander D. Kovacs, M.D.
144 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
145 MSNJ Auxiliary, Mrs. Gale Wayman
145 AMNJ Report, Paul J. Hirsch, M.D.
146 Task Force on Fetal Alcohol Syndrome
1 46 Physicians Seeking Location in New Jersey
149 CME Calendar
1 53 Letter to the Editor
154 Obituaries
155 Book Reviews
157 Information for Authors
: : New Jersey
Qrs The Cover: Sir Frederick Banting,
Nobel Laureate for the discovery of in-
sulin, was an amateur artist. The original
watercolor sketch on our cover provides
the perfect reason to discuss the art of
Banting. Read the full story on page 138.
The watercolor belongs to Mrs. Sylvia
Swern of Trenton.
92
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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VOL 81— NUMBER 2— FEBRUARY 1984
93
THE MEDICAL SOCIETY OF NEW JERSEY VOLUME '
DISCIPLINARY ACTIONS
Two cases concluded by the State Board of Medical
Examiners (SBME) in November 1983 demonstrate
situations which are a potential threat to physicians
and patients alike. These cases are discussed for the
guidance of the membership.
Experimental Drugs. A physician administered a
drug not approved by the Food and Drug Adminis-
tration (procaine polyvinylpyrrolidone) to about 15
patients without appropriate review of the substance’s
efficacy. There was no evidence that patients were
injured or that the physician knew the drug had not
been approved. The license of the doctor was
suspended for one year and stayed. He was assessed
a fine of $2,500, enjoined from the further adminis-
tration of the drug, and assessed costs of $4,160. In
addition, $960 is to be repaid to one of the patients.
Caution: Please be sure when administering drugs that
they are FDA approved for use or that you have an
investigational permit.
Life Insurance Physical Examinations. A physician,
socially aquainted with another physician and his wife,
completed a medical examination form for the couple
so that they could apply for life insurance. The phy-
sician executed the certification that indicated he had
conducted a personal physical examination of the ap-
plicants. He collected the examining fee paid by the
carrier. The factual presentation at the administrative
hearing indicated that the couple had filled in the form.
The certifying physician did not conduct an examin-
ation, nor did he fill in or dictate the answers on the
forms. The State Board ruled that the physician’s ac-
tions constituted professional misconduct and a dem-
onstrated lack of good moral character. His license
was suspended for one year and the suspension stayed.
He was assessed a penalty of $5,000 and costs of $115.
Caution: When completing life insurance examination
forms, please conduct a complete history and physical
of the applicant and thoroughly document your find-
ings and conclusions.
RABIES CONTROL
The continued migration of wildlife rabies from th
southeastern to northeastern parts of the United Statfj
is an indication that New Jersey may be vulnerable t
an outbreak of rabies.
It has been suggested by the Department of Healti
Biological Services Program that clinics be organize
on a county or regional basis. Robert F. Goldsborc
D.V.M., M.P.H., Coordinator, Veterinary Publi :
Health Biological Services Program, will be contactin g
the president of each county society to outline the pla i
of control and to seek physician support where needed
For further information, call 609-984-1378.
CERTIFICATE OF NEED
At the November meeting of the Statewide Healtlj
Coordinating Council (SHCC), the Department o;
Health recommended that a diagnostic radiological
service be deemed a health care facility and thereb’
subject to a certificate of need.
The radiological service is organized as a pro
fessional corporation and names five individuals a. I
members of the Board of Directors. All five Board
members are physicians, but none are radiologists. At
such, these physicians are not practitioners at the fa
cility; diagnostic radiological services are provided byi
radiologists who are members of a radiology group.j
In addition, the corporation employs a full-time office^
manager, a full-time secretary, two full-time x-ray;
technician’, and a part-time darkroom technician.
Utilizing the Marsh decision as a basis for the rec-
ommendation, the Health Department stated, “Only
a physician in his private practice’ is exempted from
the certificate of need requirements, but the Health1
Care Facilities Planning Act does not define this term.
Nevertheless, the term and the exemption were sub-
jects of the landmark case, Marsh v Finley. In that i
case, Dr. Albert Marsh, a radiologist and solo practi-l
tioner, sought to install a Computerized Axial Tomo- ;
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
-aphy (CAT) scanner in his private practice. It was
mnd that Marsh was undeniably a private practi-
oner who desired to augment his private practice by
stalling in his office a piece of equipment directly
dated to his radiology practice. The Court noted that
i> larsh’s practice ‘does not involve merely the
rovision of facilities for medical diagnosis and treat-
lent as in a hospital or other institutional facility, but
i he actual diagnosis and treatment of patients seeking
is aid.’ The Court also stated: ‘Plaintiffs practice and
le tools he uses are inseparable. The scanner ap-
arently will be only one of many diagnostic tools
Ivhich are incidental to this specialty of radiology.
I “A comparison of the diagnostic radiological service
i question to Dr. Marsh’s practice clearly shows that
here are significant differences. Structurally, the
i hareholders of the diagnostic radiological service
unction as investors and corporate owners, not as
ihysicians. Unlike Dr. Marsh who is engaged in ‘the
ctual diagnosis and treatment of patients’ the phy-
ician-shareholders of the diagnostic radiological ser-
ice are not radiologists. In addition, there is no con-
lection between the equipment owned by the
liagnostic radiological service and the individual prac-
ices of its physician-shareholders. Only the practice of
adiology could logically be said to be ‘inseparable’
rom the equipment housed in the facility.”
Given these findings, the Department of Health rec-
ommended that “this diagnostic radiological service be
Jeemed a health-care facility subject to the certificate
of need requirements of the Health Care Facilities
Planning Act. Such a determination is considered es-
sential for effectuating the cost-containment purposes
of nuclear magnetic resonance imaging.
WHAT DOCTOR/PATIENT
RELATIONSHIP?
Physicians no longer are physicians; they now are
referred to as providers. Recently, we were informed
that in Arizona, primary care physicians will be re-
ferred to as “gate keepers.” How much lower can we
go? Patients no longer are patients because now they
are consumers. And what happens between a physician
and a patient now is referred to as an encounter. The
context is all wrong and the result is a further weak-
ening of the doctor/patient relationship. It is as if we
are dealing with potatoes and canned corn — according
to Ernest E. Simard, M.D., Past President, College of
American Pathologists.
JCAH PUBLISHES NEW GUIDE
The Joint Commission on Accreditation of Hospi-
tals (JCAH) has announced publication of the Hospice
Standards Manual and the Hospice Self-Assessment
and Survey Guide. The Manual contains standards to
be used in the assessment of hospice programs that
apply for a JCAH accreditation survey through the
Accreditation Program for Hospice Care. The Manual
VOL. 81— NUMBER 2— FEBRUARY 1984
also includes a statement of principles reflecting the
essence of hospice care, a “Using the Manual” section
that explains how the Manual may best be suited to
the particular needs of each hospice program, and a
“General Administrative Policies and Procedures” sec-
tion that includes information on the survey process.
The Guide, a companion publication to the Manual,
is designed as an educational and self-evaluation tool
that further will assist hospice program staff in prepar-
ing for a JCAH survey.
To order books, please send $25 for each publication
to: Cashier: JCAH, 875 North Michigan Avenue, Chi-
cago, IL 6061 1. For further information regarding any
JCAH publication, telephone the Department of Pub-
lications at (312) 642-6061.
LASER SURGERY
The nation’s 11,000 ophthalmologists are turning
from scalpels to lasers as their preferred surgical in-
strument. Conditions as diverse as glaucoma and ret-
inal disease are alleviated without benefit of a knife,
and lasers are effective in radial keratomy (incisions
in the cornea), lens operations, and other procedures.
The laser is a deft tool because it permits “non-
invasive” surgery — noinvasion of the body, and no
cutting. A coherent light beam is focused inside the eye
at the point where the tip of a scalpel might otherwise
be. But only the laser “tip” has an effect; the light
waves pass harmlessly through intervening tissue.
In treating glaucoma, for example, the laser beam
makes tiny marks on the trabecular network. In
glaucoma, this meshlike network of connective tissues
gets clogged, impeding the flow of the aqueous fluid.
This fluid is to the eye as blood is to the body; it carries
nutrients throughout the eye tissues, and carries waste
products away. When the flow is obstructed, vision is
impaired.
The laser beam “scratches” portions of the
trabecular network by creating minute burns. These
burns contract the network in spots, as scabs draw
surrounding skin together. Portions of the network
thus open up, allowing the aqueous fluid to flow freely
again.
Ophthalmologists also use lasers in a “photo-
coagular” process that stops bleeding in the eye’s in-
terior. “Welding” of lenses and other eye parts is also
performed employing a laser.
Comment: Through ophthalmic laser instrumenta-
tion, the complications of surgery by scalpel are
avoided. An operation requiring three days in the hos-
pital may be performed by laser on an outpatient basis
in half an hour.
PHYSICIANS’ SERVICES
Pursuant to Executive Order No. 66 (1978), the
Division of Medical Assistance and Health Services is
proposing to readopt Subchapter 1 of the Manual for
Physicians’ Services. The proposal appeared in the De-
95
cember 19, 1983, issue of the New Jersey Register.
There are some changes on readoption, which are
designed to clarify existing Medicaid policy. Changes
include an update to the childhood immunization pol-
icy to conform with the Procedure Code Manual, de-
letion of reference to A.I.D. (Approval by Individual
Diagnosis), and revisions to the sections dealing with
pharmaceuticals to insure conformity with the Phar-
macy Manual.
RETIRED LIVES RESERVE
The following article was written by William P.
Squire, Jr., President, Professional Corporations Ltd.,
Washington, D.C.
The Medical Society of New Jersey recently has
endorsed a new benefit plan for members called Re-
tired Lives Reserve. This is the only tax-advantaged
method available to continue group term life insurance
after a physician retires. Group term life insurance
almost always is terminated either at or shortly after
retirement. If a physician dies after retirement (usually
the case), his family is left without the group term life
benefit. Retired Lives Reserve is an annual funding
program accomplished during a physician’s working
lifetime to provide enough money at retirement to
continue paying premiums on the group term policy
until he dies. Retired Lives Reserve converts a
terminable benefit into one that is guaranteed and
permanent.
Retired Lives Reserve has four tax advantages: (1)
The deposits placed in the reserve fund are tax deduct-
ible to the corporation. (2) The interest earnings on
the reserve fund are not taxed as income to the phy-
sician. (3) The proceeds at death pass income tax free
to the beneficiary. (4) If a spouse or marital trust is
named the beneficiary, the proceeds avoid federal es-
tate taxes.
This is the only property afforded all four tax advan-
tages by the Internal Revenue Code. These powerful
tax advantages make the Retired Lives Reserve Plan
particularly attractive for physicians.
Because of the changes under the new “Tax Equity
and Fiscal Responsibility Act” of 1982 (TEFRA), any
benefit over $100,000 from qualified pension or profit-
sharing plans now are subject to federal estate taxes,
and current tax rates could claim about half of the
retirement plan(s) proceeds. Thus, if conventional life
insurance is in a qualified retirement plan, its proceeds
will be subject to federal estate tax erosion. This would
not be the case with Retired Lives Reserve, where
effective planning will avoid the federal estate tax on
death benefits.
A qualified pension or profit-sharing plan tied
together with a Retired Lives Reserve Plan is th<
answer because it will provide permanent life insurance
benefits and eliminate the problem caused by conven
tional life insurance. Retired Lives Reserve gives th«j
physician the economy of term insurance with the per
manency of whole life insurance. The economy is mag
nified with tax deductible premiums and tax fret
growth. At retirement, the life insurance is paid in ful
and is perpetuated — not cancelled or transferred to the
physician causing a monetary burden. Unlike qualified
retirement plan benefits, the death benefit of a Retiree
Lives Reserve Plan is received by the physician’
beneficiary free of income tax.
TEFRA also has imposed serious limitations on thi
annual contributions and ultimate payout benefits o
qualified retirement plans. Restrictions also have been
placed on “top heavy” plans. These new statutory
limitations will have a restrictive effect on many plans
which have favored the highly compensated physician
As a result, there should be an abundance of funds
available, which in the past went to contributions to
qualified plans, and presumably now will have no
place to go.
But these released funds will have a place to go;
namely, into a Retired Lives Reserve Plan. TEFRA i
an evil wind, but even an evil wind often blows some
good.
For additional information on the new Retired Lives
Reserve Plan sponsored by the Medical Society of New
Jersey contact, Joseph C. Lucci, Director of Medical
and Insurance Affairs, MSNJ, 2 Princess Road, Law
renceville, NJ 08648.
SPORTS MEDICINE
SYMPOSIUM
The Second Annual Garden State Symposium,
sponsored by the Mid-Atlantic Chapter of the Ameri-
can College of Sports Medicine, the Medical Society
of New Jersey’s Committee on Medical Aspects of
Sports, and the Institute for Medicine in Sports of
Hamilton Hospital, will take place on April 5, 6, and
7, at the Ramada Inn, East Brunswick. For more infor-
mation contact: The Institute for Medicine in Sports:
of Hamilton Hospital, P.O. Box 2621, Hamilton, NJ
08690, or call Mrs. Ann Clutter (609) 586-7900, x6402.
FIN!
Some people see things as they are, and ask why?
Some people see things that never were, and ask why
not- Robert Frost
1HE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
96
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Compare these figures (based on a $20,000 vehicle):
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total due: $5754 $435
So by leasing, you’ve got $5319 savings on your
initial outlay, plus $1 1 9 a month, to invest any
way you’d like! And insurance is available to
qualified N.J. motorists for as little as $480 a
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TAXES AND ACCOUNTING
AFFECT YOUR PROFITABILITY!
GEIN, CONNOLLY & SWITAJ
Certified Public Accountants
Central New Jersey CPA Firm Providing Tax,
Accounting and Management Advisory Services
to the Medical Profession.
721 North Beers Street
Holmdel, New Jersey 07733
(201) 739-2020
PROGESTERONE SUPPOSITORIES
25 mg., 50 mg., 100 mg., 200 mg., & 400 mg
Boric Acid Suppositories 600 mg.
in Polyethylene Glycol Base for
Vaginal Use, are now being
compounded at the following Pharmacy
Hidden Lakes Pharmacy
2039 Rt. #27, Somerset, N.J. 08873 201-821-8500
Howard L. Rubenstein, R.Ph.
Specific dosage and ingredient requirements can be tailorec
to your patients needs. We specialize in compoundinc
prescriptions.
Delivery available to your patients home. Call for
details.
Doctors: Write your own prescription
to cure insurance pains . . .
F\, Prescription
Prescription
m m - —
Name MSNJ Member
A
Name
MSNJ Group
Blue Cross/ilue Shield
Major Medical and
Dental Insurance
that provides:
- Flexible plans
- Comprehensive benefits
- Low, competitive rates
- Centralized Administration
Designed and Administered by
(DONALD E SM ITH (V ASSOCIATES!
Address
Phone
Please send more information
on the MSNJ
□ Blue Cross/Blue Shield Program
□ Major Medical Program
□ Group Dental Program
Return to:
Donald F. Smith & Associates
One Airport Place, Route 206 North
P.O. Box 2197,
Princeton, New Jersey 08540
(609) 924-8700, (201) 622-6046
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
PROFESSIONAL LIABILITY COMMENTARY*
Negligence Suits, Baby Doe Hotline,
ind Emergicenters
he partners of a deceased physician
were liable for $375,000 in damages
for his negligent treatment of a pa-
ent, the highest court of Massachusetts ruled in Van Dyke
Bixby, 448 N.E. 2d 353 (Mass. Sup. Jud. Ct„ April 8, 1983).
The physician practiced medicine with several other phy-
cians in 1959, when he operated on the patient for cancer
f the rectum. In 1962, the physicians formed a partnership,
in July 1969, the patient returned to the physician complain-
ig of severe pain. He performed two operations — one for
twisted bowel and one for adhesions. A single Penrose
rain was inserted during one of the operations.
Two months later the patient came back to the physician
/ith an abscess in his perineum, which the physician drained,
'he drainage persisted and he tried to cauterize the abscess
Vith a silver nitrate stick. He told his patient that those
iroblems often take a long time to go away. On January
, 1970, the partnership ended and a corporation succeeded
t. The patient saw the physician several times during the first
lalf of 1970.
The abscess continued to drain during the next several
/ears, causing a substantial unpleasant odor and consider-
ible discomfort. In 1978, another physician performed a
sinogram. The perineal sinus was explored, part of the pa-
tient’s coccyx was removed, and a Penrose drain was found
above the sinus tract and in front of the coccyx.
The treating physician died in 1975, and the patient filed
suit against the nine physicians who were his partners. A trial
court returned a verdict of $375,000 in favor of the patient
and the physicians appealed.
On appeal, the court said that the evidence was sufficient
to show that a partnership existed. There was testimony that
the patient received joint bills, that a certificate filed with
the city clerk was signed by all ten physicians, that they
insured their liability as partners, and that certain of the
physicians stated that they were partners.
The evidence was sufficient to find the physician negligent
for failing to remove the Penrose drain and delaying in
taking action to correct the cause of the drainage. (The
Citation, November 1, 1983, Vol. 48, No. 2)
BABY DOE SQUADS TRACK THREE VALID
COMPLAINTS
Responding to 33 complaints on the “Baby Doe Hotline,"
representatives of the Department of Health and Human
Services sent teams of physicians and civil rights in-
vestigators to check out 1 1 complaints. Complaints were
unsubstantiated in eight cases, but in three others, they
helped save the lives of handicapped infants, Time magazine
reported September 26, 1983.
Interestingly, the problem in the three cases is one that
may sometimes be at the root of malpractice suits. “Doctors
seem to be unaware of new techniques for treating birth
defects,” the magazine reported. The American Academy of
Pediatrics, which with other professional organizations is
fighting against the controversial “Baby Doe” regulations
that interpose the government between physicians, hospitals,
and the parents of handicapped infants, agrees, arguing that
the best way to help afflicted babies is by “better educating
doctors about medical advances” and by creating infant
bioethical review committees in hospitals. (Medical Liability
Monitor, October 27, 1983, Vol, 8, No. 10)
DID YOU KNOW . . .
The United States Supreme Court on October 3, 1983, let
stand an Illinois Supreme Court ruling that said two Chi-
cago-area couples could not recover the costs of raising
children born after sterilization procedures? It was the first
time that the “wrongful birth” issue reached the nation's
highest court. The justices dismissed the appeal without com-
ment. (Medical Liability Monitor, October 27, 1983, Vol. 8,
No. 10)
Reports from New York indicated that the JUA will re-
quest a 165 percent increase in malpractice insurance?
California and Missouri courts have ruled that osteopaths
are prohibited from using the M.D. designation?
This item from the Department of Professional Liability Control.
MSNJ, was prepared by James E. George, M.D., J.D., and A.
Ronald Rouse who are, respectively. Director of the Department
and Director of Special Projects.
VOL. 81— NUMBER 2— FEBRUARY 1984
99
their staff physicians to malpractice suits, medico-legal e.
perts say. Courts are likely to find for the plaintiff in cast
involving a center’s refusal to treat a patient whose conditic ;
was too complicated, the lawyers say. In one such case, a
emergicenter settled a suit by a family of a diabetic patiei
who died while being transferred to a hospital. Doctors an
centers could get into more legal hot water is they fail t
provide followup care, arrange appropriate referrals, c
otherwise appear to abandon the patient. ( Medical Ecoi lj|
omics, November 14, 1983)
(
1 1
V
p
The Medical Society of New Jersey
PRESENTS
MEDICAL MALPRACTICE SEMINARS
FOR AS LITTLE AS $45.00
Professional Liability and the Obstetrician/Gynecologist
Professional Liability and the Orthopedic Surgeon
Professional Liability and the Anesthesiologist
Professional Liability and the General Surgeon
Professional Liability and Internal Medicine
Neurosurgery and the Law
The Department of Professional Liability Control of the Medical Society of New Jersey has developed
professional liability video tapes aimed at specific medical specialties. The video tapes incorporate a
“talk show” format featuring James E. George, a physician-attorney, and physician(s) representing the J
medical specialty of the tape. Each of the 45-55 minute video tapes is designed to encourage postviewing
discussion and is available for a $45.00 rental fee. All tapes are available in 3A inch, Beta, and VHS.
TOPICS INCLUDE
• Physician to physician and
physician to staff communications
• Group practice
• Emergency room setting
• Three “R’s” of malpractice prevention
Category I AMA accreditation can be obtained if the video tapes are used as part of a planned
program in conjunction with a moderator.
For more information please contact the Department of Professional Liability Control at the Medical
Society of New Jersey, (609) 896-1766.
All tapes carry the copyright of MSNJ and may not be reproduced or distributed in any form or
fashion without the express written consent of the Medical Society of New Jersey.
Copyright 1982.
• General assessments of
professional liability
• Informed consent
• Multiple-physician consultants
• Medical records
Board of Governors of the Medical Inter-Insurance Ex-
change of New Jersey has voted to file a rate request that
will increase all professional liability rates through the Ex-
change by 13.7 percent effective February 1984?
POTENTIAL LEGAL PITFALLS LIE AHEAD FOR
EMERGICENTERS
Use of the term “emergency” by freestanding emergency
centers creates expectations that may expose the centers and
100
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
WORLDS UNDER DRG...
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reports, handling all the necessary paperwork and
delivering products and services in all areas of
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HoMed provides the kind of quality care you ex-
pect...keeping in mind that the physician/patient
relationship is foremost in the continued care of
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VOL. 81— NUMBER 2— FEBRUARY 1984
101
JUST ONCE-DAILY
FOR INITIAL THERAPY
IN HYPERTENSION
— -
,
Unique, once-daily formulation
providing comprehensive
cardiovascular protection
INDERAL LA offers the antihypertensive and car-
diovascular benefits of INDERAL-with the additional
advantage of convenient, single daily dosage. With a
unique controlled-release formulation, INDERAL LA
(propranolol HC1) provides sustained plasma levels
and consistent, 24-hour beta blockade.
Smooth 24-hour
blood pressure control
In controlled clinical studies, INDERAL LA effec-
tively maintained systolic and diastolic blood pressure
reductions with single daily dosing.
Avoids the potassium loss
associated with diuretics
INDERAL LA controls blood pressure without the
problem of hypokalemia often associated with long-
term diuretic therapy. Like conventional INDERAL,
INDERAL LA should not be used in the presence of
congestive heart failure, sinus bradycardia, heart
block greater than first degree, or bronchial asthma.
102
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
Start with 80 mg once daily . . .
Dosage may be increased to 120 mg or 160 mg once
daily as needed to achieve additional control. When
converting patients from other beta blockers, includ
ing INDERAL tablets, start with the nearest milli-
gram equivalent of INDERAL LA once daily and
evaluate clinical results to determine if dosage
adjustment is necessary. For arrhythmias, use
conventional INDERAL (propranolol HC1) tablets.
ONCE-DAIL y
INDERAL LA »
(PROPRANOLOL HCI) “
n
BHl|
n
w
80 mg
RALU
HI
ini
120 mg 160 mg
The appearance of INDERAL LA capsules
is a registered trademark of Ayerst Laboratories.
Please see next page for brief summary
of prescribing information.
VOL. 81— NUMBER 2— FEBRUARY 1984
103
The one to count on
for HYPERTENSION, ANGINA
and prevention of MIGRAINE.
ONCE-DAILY
INDERALLA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION SEE PACKAGE CIRCULAR .)
INDERAL1 LA BRAND OF propranolol hydrochloride
(Long Acting Capaulos)
DESCRIPTION. Inderal LA is formulated !o provide a sustained release of propranolol
hydrochloride. Irideral LA is available as 80 mg. 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOOY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80. 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism ot
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
ffect, INDERAL LA has 1
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced increases in the heart rate
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length end diastolic
pressure and systolic election period. The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity.
In dosages greater than required for beta-blockade, INDERAL also exerts a quimdine-
like or anesthetic-like membrane action which affects the cardiac action potential The
significance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the pial vessels of the brain
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient. But there are also
situations in which sympathetic stimulation is vital For example, in patients with severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pactorls Du© to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary,
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
INDERAL6 WARNINGS* unless ,he failure is secondary to a tachyarrhythmia treatable with
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of diqitalis on heart
muscle M
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
'n son2® cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosaqe
should be gradually reduced over at least a few weeks, and the patient should be
, a9a|nst interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advisa-
ble to reinstitute INDERAL therapy and take other measures appropriate for the manage-
ment of unstable angina pectoris. Since coronary artery disease may be unrecognized it
may be prudent to follow the above advice in patients considered at risk of havinq occult
atherosclerotic heart disease who are given propranolol for other indications
NonalUrgic Bronchospasm (a.g., chronic bronchitis. •mohvsAmal —
RA^ENTS WITH I3RONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY; The necessity or desirability of withdrawal of beta-blocking thei
prior to major surgery is controversial. It should be noted, however, that the impaired abilii
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesth
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of b
receptor agonists and its effects can be reversed by administration of such agents, (
dobutamine or isoproterenol. However, such patients may be subject to protracted se'.,
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported
beta blockers
DIABETES AND HYPOGLYCEMIA; Beta-adrenergic blockade may prevent the
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes!
acute hypoglycemia In labile insulin-dependent diabgtes. In these patients, it may be rr
difficult to adjust the dosage of insulin
THYROTOXICOSIS; Beta blockade may mask certain clinical signs of hyperthyroidn
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptc
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function te;
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bl
reported in which, after propranolol, the tachycardia was replaced by a severe bradyca;
requiring a demand pacemaker. In one case this resulted after an initial dose of 5
propranolol
PRECAUTIONS. General: Propranolol should be used with caution in patients with impai'
hepatic or renal function INDERAL is not indicated for the treatment of hypertens1
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patie1
should be told that INDERAL may interfere with the glaucoma screening test. Withdrawal r:
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dises
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re;
pine should be closely observed if INDERAL is administered The added catecholami
blocking action may produce an excessive reduction of resting sympathetic nervous acti
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, ororthost;
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals hi
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studiei
both rats and mice, employing doses up to 150mg/kg/day, there was no evidence of signific
drug-induced toxicity There were no drug-related tumorigenic effects at any of the dosj
levels Reproductive studies in animals did not show any impairment of fertility that v
attributable to the drug
Pregnancy: Pregnancy Category C. INDERAL has been shown to be embryotoxic
animal studies at doses about 10 times greater than the maximum recommended human do
There are no adequate and well-controlled studies in pregnant women INDERAL sho
be used during pregnancy only if the potential benefit justifies the potential risk to the fet
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercised wf
INDERAL is administered to a nursing woman
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and ht
rarely required the withdrawal of therapy.
Cardiovascular bradycardia; congestive heart failure, intensification of AV block; hyp
tension, paresthesia of hands; thrombocytopenic purpura; arterial insufficiency usually of t
Raynaud type
Central Nervous System, lightheadedness; mental depression manifested by insomr
tessitude, weakness, fatigue, reversible mental depression progressing to catatonia; visi
disturbances; hallucinations; an acute reversible syndrome characterized by disorientation
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, a
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarrhr
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with achi
and sore throat, laryngospasm and respiratory distress
Respiratory : bronchospasm.
p ^Hematologic. agranulocytosis, nonthrombocytopenic purpura, thrombocytoper
Auto-Immune In extremely rare instances, systemic lupus erythematosus has be
reported
Miscellaneous alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imp
tence, and Peyronies disease have been reported rarely. Oculomucocutaneous reactio
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practol
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride ir
sustamed-release capsule for administration once daily If patients are switched from INDER/
table s to INDERAL LA capsules, care should be taken to assure that the desired therapeu
f\inppAim?MncDACil ilrl^.ER^L.,LA should not be considered a simple mg for mg substitute ’
INUEHAL INDERAL LA has different kinetics and produces lower blood levels. Retitration m
be n®=essa4Y especially to maintain effectiveness at the end of the 24-hour dosing interv
winroAi , IENS 'ON— Dosage must be individualized. The usual initial dosaqe is 80 n
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may I
increased to 120 mg once daily or higher until adequate blood-pressure control is achieve
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosaqe of 6*
mg may be required The time needed for full hypertensive response to a given dosaqe
variable and may range from a few days to several weeks
ANGINA PECTORIS— Dosage must be individualized Starting with 80 mg INDERAL L
once daily, dosage should be gradually increased at three to seven day intervals until optimu
response is obtained Although individual patients may respond at any dosaqe level tl
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value ar
safety of dosage exceeding 320 mg per day have not been established
(see WARNINGS) *° ^ dlscontinued' reduce dosage gradually over a period of a few weel
MIGRAINE— Dosage must be individualized The initial oral dose is 80 mq INDERAL L
once daHy The usual effective dose range is 160-240 mg once daily. The dosage may t
ncrcasprt nr^rii \/ tn arhiowo nntim, ,rr^ U. .,_ _ . . T, 1
™.9.r?Lnf ProPhy|axis If a satisfactory response is n
°h,a'iHeK wjthin ,our ,0 SIX weeks attar reaching the maximum dose. INDERAL LA theraj
several ^veeks'061""'116^ ** ma^ de advisable ,0 withdraw the drug gradually over a period
PFYnFAimr nniASrUpBA0AR,TIKC STEN°SIS-80-160 mg INDERAL LA once daily,
too Sdlo perm?t Adequate d'recti'oTs fo? °n the US6 °' the drU9 'n ,h'S 396 9r0up 3 1
•The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratorie
Ayerst
8688/88
AYERST LABORATORIES
New York, N Y. 10017
DITORIALS
Blood Banks and AIDS
The panic which has spread through our nation about
cquired immunodeficiency syndrome (AIDS) has had sig-
lificant real and imagined effects on blood banks, blood
lonors, and blood recipients.
In this issue (page 125), Smith, Brennan, and McDonough
lebate the legal implications of refusal to accept blood dona-
ions from Haitians, heroin addicts, and homosexuals, in
erms of privacy, equal protection of the laws, constitutional
ights, and public health. Their conclusions seem to offer
omfort to the blood banks.
In order to provide equal comfort to recipients of blood
ransfusions and to encourage the continued supply of blood
jo banks from donors who are not in the segments of the
)opulation which appear to be the exclusive carriers of
\IDS, a statement was released to the public media by the
Blood Banking Task Force for New Jersey.* The statement
was endorsed by the New Jersey State Department of Health
ind the New Jersey Blood Bank Association, and was ap-
)roved by the Board of Trustees, MSNJ.
Analysis of the data available from national
and state public health authorities supports the
conclusion that acquired immunodeficiency
syndrome (AIDS) is not being spread by blood
transfusions from voluntary donors. Ap-
propriate public health measures are being em-
ployed by all blood collection facilities in the
state of New Jersey.
All blood transfused to patients in New Jer-
sey is collected from volunteer blood donors.
Additional screening methods currently em-
ployed in New Jersey include rigorous medical
screening and the exclusion of donors who are
at high risk of exposure to AIDS. These
measures have been shown to be effective.
One result of the excessive fears concerning
possible transfusion-associated AIDS has been
requests by patients for blood donors selected
from family members, friends, or associates
(“directed donors”). We agree with the Ameri-
can Association of Blood Banks, the American
Red Cross, and the Council of Community
Blood Centers, that: ‘A system of directed
donations may create intense pressure for fam-
ily members and friends who may therefore be
untruthful about their ability to meet donor
requirements.’ Therefore, we are concerned
that such donations may be less safe than
blood donated by volunteers at blood centers
and hospitals, to meet the community’s needs.
Directed donations strongly are discouraged.
Physicians can reassure their patients that the
community’s blood supplies are not considered
a source of the spread of AIDS.
People in good health, who are not members
of groups known to be at high risk of exposure
to AIDS, are urged to give blood to meet the
needs of patients in New Jersey hospitals.
Blood donation is carried out under strictly
hygienic conditions, with sterile, new, dis-
posable equipment, used only once for the
donation. The donation is perfectly safe for the
donor.
Physicians who refer persons to blood banks as donors
or who order blood transfusions for their patients may wish
to utilize the statement to answer questions on the subject.
A.K.
*Frank Campo, M.D., a member of the Board of Trustees, was
MSNJ’s liaison of the Task Force.
Sir Frederick G. Banting — The Artist
What did William Carlos Williams, M.D., and Sir Freder-
ick G. Banting, M.D., have in common? They both were
physicians, recipients of prestigious awards (Williams won
the Pulitzer Prize and Banting won the 1923 Nobel Prize),
artists, art collectors, and friends and admirers of artists.
Williams’s artistic interest was international with head-
quarters in New York City. Banting, however, was parochial
in his artistic taste, being limited primarily to Canada.
We were privileged to discover and borrow an original
painting by Dr. Banting and to reproduce it as a cover for
this issue. Readers are encouraged to learn more about Sir
Frederick (pages 138-139) and to share our admiration for
one who, like Williams, was able to utilize scientific and
artistic talents for the betterment of mankind. A.K.
VOL. 81— NUMBER 2— FEBRUARY 1984
105
Baby Doe and the Prognosis Committee
A child is born; a child dies: is there another event more
likely to bring to our eyes the tears of sorrow? It is not hard
to understand that Baby Does born, living, dead, and yet
to be born, elicit from health workers the desire to do all
that can be done to alleviate suffering and preserve life. Our
common humanity lays upon us the need to do what we can.
Quality of care is our first consideration. Is it really?
In a recent issue of the ‘'Physician Legal Bulletin” pub-
lished in The Journal , George and Quattrone review some
of the issues concerning when not to treat and when to allow
life to end.1 Should all available medical resources be
marshaled for everyone? If not: How does one choose? Who
chooses? What are the criteria of choice?
Costs of care for the child with serious abnormalities may
be in excess of any family’s ability to pay. One child who
receives a liver transplant may use up all the funds available
for the state of New Jersey, for a year, by legislative ap-
propriation, for out-of-state hospital care. It has become
recognized widely that if every person received all the ben-
efits of health care, our country would not have enough
money to pay for all.
If we are to live in a time of shortage, health care resources
clearly will need to be allocated. How is this to be done?
In some parts of the world, guns, physical strength, or money
may determine resource allocation. Our country has gone far
in the direction of equalizing access to health care. Some feel
it has not gone far enough.2 If there is not enough to go
around, some individuals will be provided for and others will
not. Whether or not we like the idea, our society has de-
veloped criteria to determine the outcome when individuals
compete for satisfaction of needs. At present, outcomes are
determined by: enthusiasm and skill of the physicians; vigor,
social class, and resources of the patient or parents who
conceived a child; cultural and ethical mores of the com-
munity in which all these persons live; and political,
financial, and geographic situations of a particular state.
Is it fair to allow such results? Is it more in keeping with
the historical policies of equality of opportunity of our coun-
try to develop more systematic methods for allocating care?
When an infant is born with serious congenital ab-
normalities (structural or physiological), attending phy-
sicians rapidly must determine what steps are needed to
correct the problem. They must prognosticate the results of
modern technological treatment. A child with deficient B and
T cell function, delivered by an aseptic method into a sterile
life-island, survives. Delivered vaginally, into even a clean
nursery, the child dies. An infant with short gut syndrome
survives with total parenteral nutrition. An infant with con-
genital hypothyroidism survives if detected early enough and
is normal if treated properly. Sterile life-islands are available
at only a few places in this country. Parenteral nutrition is
offered at every tertiary care institution for infants, and in
some secondary centers. Treatment for hypothyroidism
should be available everywhere.
If the situation is complicated because the treatment i
long, difficult, and expensive, it is unfair to offer treatmer
without helping the family sustain the financial, educationa
and emotional burden involved.3
If the situation is one in which the quality of life is sue
as to cause a prudent person to doubt if it is worthwhile
then we have Baby Doe. Now the situation has become ver
comparable to that of the elderly — past all caring.1 Much ha
been made of the need for review of parental decisions, wit
respect to the treatment to be offered children. Once, a chili
was property, to be disposed of according to the wishes o
the father. It is recognized now that the state may interven
to protect children to see that they are given appropriatii
treatment, and to safeguard children from abuse or neglect!
It is but a small step between intervention upon notice o
probable cause for suspicion (our current child abuse legis
lation) and systematic examination of parental decision
about a class of children (those with birth defects). Should,
all such instances be reviewed by an agency of government
Are records to be opened? Privacy invaded? Parents’ desire
overruled, condemning them to later financial and emotiona
bankruptcy? The decisions are not easy. The first Baby Do
had Down’s syndrome and intestinal obstruction. Treatmen
was straightforward. Who is to say that the child witl
Down's syndrome does not enjoy life, although the paren
may find life more burdensome. The second had spina bifid;
and multiple defects. It is known that such children usuall;
are very severely retarded, immobile, and highly likely no
to survive. One could describe anecdotes of case after case
There is a precedent known to almost every physician 01
a hospital staff: the prognosis committee.1 Usually composec
of several physicians with expertise in the specific illness am
one or more neurologists or neurosurgeons, the committei
reviews patients considered to have brain death, to determim
when it is appropriate to advise the abandonment of effort;
to prolong life. It may be that members of the clergy or othe
nonphysicians serve on such a committee. The principle o !
group wisdom to help the practitioner and the unhappy
family in reaching a repugnant decision is well establishec
and usually functions well.
Cannot such a precedent guide us in offering care to the
seriously abnormal newborn, for whom the quality of lift
under the most ideal circumstances may be compromised tet
an intolerable degree? The system may not be perfect, bu
it works in many hospitals. Privacy is affirmed, the public
is served, and the rights of infants, parents, and state are
protected.
Avrum L. Katcher, M.D
REFERENCES
1. George JE, Quattrone M: Physician legal bulletin. J Med Sot.
A7 80:12, 997.
2. Courter J: Time to act on organ transplants. J Med Soc Nj
80:12, 1052.
3. Will GF: The Washington Post, December 1983, p. A23.
106
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
HOSPITAL GOVERNING BOARDS*
Hospital Staff Privileges
for Nonphysicians
T
he subject of hospital staff privi-
leges for nonphysicians has been
heating up over the last few years.
More and more nonphysician professionals, including
podiatrists, nurse midwives, and psychologists, have been
attempting to gain medical staff privileges in order to prac-
|ice their professions within the confines of the hospital.
Of necessity, these nonphysician professionals are unable,
[by virtue of their limited scope of training and licensure, to
assume complete responsibility for the care of a patient as
s the case for a licensed physician. Therefore, hospitals
which have granted clinical privileges to these nonphysician
professionals have had to create some medical staff oversight
mechanism to review their cases while in the hospital or to
fpoadmit to the combined service of the nonphysician and the
[oversight physician.
Many physicians have voiced their concern that these ar-
rangements might expose them to liability for the negligent
acts of the nonphysician professional. Hospitals, too, have
[(voiced concern over nonphysician staff privileges because
[hospitals also know that they will be responsible in one form
or another for the outcome of care rendered by these
nonphysician professionals. A recent podiatric malpractice
(case clearly highlights the fact that everybody’s anxieties in
these areas are well-founded.
The case of Elam v College Park Hospital, 1 32 Cal.App.3d
332, was decided by the California Court of Appeals on June
25, 1982. In the patient’s complaint, the plaintiff stated that
a licensed podiatrist performed negligent podiatric surgery
at the hospital to correct bilateral bunions and bilateral
hammer toes. The patient was admitted to the hospital for
surgery by the podiatrist and for treatment by a medical
doctor member of the medical staff.
This admission to two professionals occurred pursuant to
a hospital coadmission procedure requiring concurrence of
the medical doctor before admitting the podiatric patient.
It was not contested that the medical doctor had assumed
responsibility for the overall medical care of that patient
including the taking of the medical history and the per-
formance of the physical examination to insure that podiatric
surgery was not contraindicated.
The facts further revealed that the podiatrist was entirely
an independent contractor with the hospital, and never an
employee or agent. The podiatrist never was paid by the
hospital, operated his own office, and billed the patient
directly. The patient in this case personally had selected the
podiatrist for medical and/or surgical treatment. The
podiatrist had complied with the hospital’s credentialing pro-
cess and the hospital’s governing board granted him
podiatric surgery privileges in April 1975. Apparently, the
podiatrist had three other malpractice cases pending against
him by the same plaintiff s attorney who represented the
patient in the Elam case. The hospital in this case argued
that it did not owe its patients a legal duty to exercise
reasonable care in selecting, reviewing, and periodically
evaluating the competency of the physicians and podiatrists
it permitted to treat patients within its facilities. This argu-
ment was not well received by the court which cited numer-
ous references underscoring the integrity of the doctrine of
hospital corporate liability.
The court went on to conclude: “In summary, we hold
a hospital as accountable for negligently screening the com-
petency of its medical staff to insure the adequacy of medical
care rendered to patients at its facility.” The court went on
to quote various provisions of the California Administrative
Code, more particularly Title 22, section 70703 as follows:
“(a) Each hospital shall have an organized medical staff
responsible to the governing body for the fitness, adequacy,
and quality of the care rendered to patients of the hospital;
(b) The medical staff shall be composed of physicians and,
where dental or podiatric services are provided, dentists or
podiatrists.”
Thus, the hospital cannot avoid liability for podiatrist
members of its staff due to the hospital’s overall responsi-
bility as a corporate entity for what transpires within the
hospital confines. Physicians also must be aware of the clear
fact that they will be held accountable for any patient whom
they have coadmitted with a nonphysician. Hospitals and
medical staffs should exercise great care and caution in
pursuing solutions to the problem of granting privileges to
nonphysician professionals.
One thing is certain, however, and that is that an element
of responsibility always will remain on the shoulders of the
hospital and physician who are responsible for evaluating
and overseeing the care rendered by these nonphysician pro-
fessionals. J.E.G.
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, J.D., Ex-
ecutive Director, MSNJ; and James E. George, M.D., J.D., Director
of the Department of Professional Liability.
VOL. 81— NUMBER 2— FEBRUARY 1984
107
WHY
ama9
immediate acces ^ socjo.econom-
medical, scie ^ mainla,ns a
jc information. > journals, and
,atge collection of books,^^ ^
microfilm and p information
aCC6SS throuQb computerized data
S0U'CfTtle AMA library. It'S one more
good^eaaorTwhy you should
of the AMA.
To Join, ctate medical
Contact you. coun^rnSta.eMember
society or w"te_ Qearborn Street,
ship, AMA, 535 North Dea ^
Chicago, Illinois 60610
(312)751-6196.
References:
1. Stone PH. Turi ZG, Muller JE Efficacy of nifedipine therapy for refractory anqina
pectoris Am Heart J 104:672-681, September 1982.
2. Antman E, Muller J, Goldberg S, et al: Nifedipine therapy for coronary-artery
spasm: Experience in 127 patients. N Engl J Med 302:1269-1273, June 5, 1980
BRIEF SUMMARY
PROCARDIA " (nifedipine) CAPSULES For Oral Us
INDICATIONS AND USAGE: I. Vasospastic Angina: PROCARDIA (nifedipine) is indicated for tf
management of vasospastic angina confirmed by any of the following criteria: 1 ) classical pattei
of angina at rest accompanied by ST segment elevation. 2) angina or coronary artery spasm prr
voked by ergonovine, or 3) angiographically demonstrated coronary artery spasm . In those patienl
who have had angiography, the presence of significant fixed obstructive disease is not incompatib 1
with the diagnosis of vasospastic angina, provided that the above criteria are satisfied. PROCARDI
may also be used where the clinical presentation suggests a possible vasospastic component bi
where vasospasm has not been confirmed, eg. where pain has a variable threshold on exertion r
in unstable angina where electrocardiographic findings are compatible with intermittent vase
spasm, or when angina is refractory to nitrates and/or adequate doses of beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated ft
the management of chronic stable angina (effort-associated angina) without evidence of vasospasr
in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrate
or who cannot tolerate those agents.
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controlle
trials of up to eight weeks duration in reducing angina frequency and increasing exercise tolerance
but confirmation of sustained effectiveness and evaluation of long-term safety in those patients ar
incomplete.
Controlled studies in small numbers of patients suggest concomitant use of PROCARDIA an
beta blocking agents may be beneficial in patients with chronic stable angina, but available infort
mation is not sufficient to predict with confidence the effects of concurrent treatment, especially i
patients with compromised left ventricular function or cardiac conduction abnormalities. When in
troducing such concomitant therapy, care must be taken to monitor blood pressure closely sine
severe hypotension can occur from the combined effects of the drugs (See Warnings.)
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect o
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol
erated hypotension These responses have usually occurred during initial titration or at the time o
subsequent upward dosage adiustment, and may be more likely in patients on concomitant bet;
blockers.
Severe hypotension and/or increased fluid volume requirements have been reported in patient,"
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypas:
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to b(
due to the combination of PROCARDIA and a beta blocker, but the possibility that it may occur with
PROCARDIA alone, with low doses of fentanyl, in other surgical procedures, or with other narcotit
analgesics cannot be ruled out. In PROCARDIA treated patients where surgery using high dost
fentanyl anesthesia is contemplated , the physician should be aware of these potential problems and
if the patient's condition permits, sufficient time (at least 36 hours) should be allowed fo
PROCARDIA to be washed out of the body prior to surgery
Increased Angina: Occasional patients have developed well documented increased frequency du-
ration or severity of angina on starting PROCARDIA or at the time of dosage increases. The mech-
anism of this response is not established but could result from decreased coronary perfusion
associated with decreased diastolic pressure with increased heart rate, or from increased demand
resulting from increased heart rate alone.
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with-
drawal syndrome with increased angina, probably related to increased sensitivity to catechol-
amines Initiation of PROCARDIA treatment will not prevent this occurrence and might be expected
to exacerbate it by provoking reflex catecholamine release There have been occasional reports of
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation. It is important
to taper beta blockers if possible, rather than stopping them abruptly before beginning
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed heart
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater risk for
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascular
resistance, careful monitoring of blood pressure during the initial administration and titration
of PROCARDIA is suggested Close observation is especially recommended for patients already
taking medications that are known to lower blood pressure. (See Warnings )
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso-
dilation and not due to left ventricular dysfunction, occurs in about one in ten patients treated with
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diuretic
therapy With patients whose angina is complicated by congestive heart failure, care should be taken
to differentiate this peripheral edema from the effects of increasing left ventricular dysfunction
Drug interactions: Beta-adrenergic blocking agents: (See Indications and Warnings.) Experience
m over 1400 patients in a non-comparative clinical trial has shown that concomitant administration
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasional
literature reports suggesting that the combination may increase the likelihood of congestive heart
failure, severe hypotension or exacerbation of angina.
Long-acting nitrates: PROCARDIA may be safely co-administered with nitrates, but there have
been no controlled studies to evaluate the antianginal effectiveness of this combination.
Digitalis: Administration of PROCARDIA with digoxin increased digoxin levels in nine of twelve
normal volunteers The average increase was 45%. Another investigator found no increase in di- 1
goxin levels in thirteen patients with coronary artery disease In an uncontrolled study of over two
hundred patients with congestive heart failure during which digoxin blood levels were not meas-
ured, digitalis toxicity was not observed Since there have been isolated reports of patients with
elevated digoxin levels, it is recommended that digoxin levels be monitored when initiating, adjust-
ing, and discontinuing PROCARDIA to avoid possible over- or under-digitalization.
Carcinogenesis, mutagenesis, impairment of fertility When given to rats prior to mating, nife-
dipine caused reduced fertility at a dose approximately 30 times the maximum recommended hu-
man dose
Pregnancy: Category C. Please see full prescribing information with reference fo teratogenicity in i
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys.
ADVERSE REACTIONS: The most common adverse events include dizziness or light-headedness,
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of pa-
tients, transient hypotension in about 5%, palpitation in about 2% and syncope in about 0.5%.
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antian-
ginal medication Additionally, the following have been reported: muscle cramps, nervousness,
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shaki-
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus urticaria fe-
ver, sweating, chills, and sexual difficulties. Very rarely, introduction of PROCARDIA therapy was
associated with an increase in anginal pain, possibly due to associated hypotension
In addition, more serious adverse events were observed, not readily distinguishable from the nat-
ural history of the disease in these patients. It remains possible, however, that some or many of
these events were drug related Myocardial infarction occurred in about 4% of patients and conges-
tive heart failure or pulmonary edema in about 2%. Ventricular arrhythmias or conduction disturb-
ances each occurred in fewer than 0 5% of patients.
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline phos-
phatase, CPK, LDH, SGOT, and SGPT have been noted, and a single incident of significantly ele-
vated transaminases and alkaline phosphatase was seen in a patient with a history of gall bladder
disease after about eleven months of nifedipine therapy. The relationship to PROCARDIA therapy is
uncertain These laboratory abnormalities have rarely been associated with clinical symptoms.
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive world
literature
SDnrADm,lV\n,,,,r?ange' son 9e'a,in " hucahuia CAPSULE contains 10 mg of nifedipine
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069-2600-66), 300 (NDC 0069-
2600-72), and unit dose (10x10) (NDC 0069-2600-41). The capsules should be protected from
light and moisture and stored at controlled room temperature 59° to 77°F ( 15° to 25°C) in the man-,
ufacturer's original container
More detailed professional information available on request
© 1982, Pfizer Inc.
LABORATORIES DIVISION
108
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
otes from an unsolicited
er received by Pfizer from an
jina patient.
He this patient 's experience
epresentative of many
solicited comments received,
all patients will respond to
cardia nor will they all
pond to the same degree !
"My doctor switched me to
PROCAR Dl A M as soon as it became
available. The change in my condition
is remarkable."
"I shop, cook and can plant
flowers again."
"I have been able to do volunteer
work. .and feel needed and useful
once again."
83, Pfizer Inc.
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0.5%).
for the varied faces of angina
,
"My daily routine consisted of
sitting in my chair trying to stay alive."
ocardia is indicated for the management of:
Confirmed vasospastic angina.
Angina where the clinical presentation suggests a possible
sospastic component.
Chronic stable angina without evidence of vasospasm in
itients who remain symptomatic despite adequate doses of
;ta blockers and/or nitrates or who cannot tolerate these
;ents. In chronic stable angina (effort-associated angina)
tOCARDIA has been effective in controlled trials of up to
§ht weeks' duration in reducing angina frequency and
:reasing exercise tolerance, but confirmation of sustained
:ectiveness and evaluation of long-term safety in these
itients are incomplete.
PROCARDIA
(NIFEDIPINE)
Capsules 10 mg
Please see PROCARDIA brief summary on adjoining page
VOL. 81— NUMBER 2— FEBRUARY 1984
109
Postmyocardial Infarction Rupture
of the Ventricular Septum
SHASHI K. AGARWAL, M.D., JACOB HAFT, M.D.,
JONATHAN GOLDSTEIN, M.D., Newark*
Cross-sectional echocardiography has acquired an important role in
the evaluation of seriously ill patients with complicated myocardial
infarction. The case presented illustrates the quick, accurate, and
hazard- free capability of two-dimensional echocardiography for acute
postmyocardial infarction septal rupture.
Cross-sectional echocardiography
has allowed assessment of
myocardial dysfunction in coronary
artery disease. I,J It especially has been useful in recognizing
complications of ischemia such as ventricular aneurysm,3
ventricular rupture with pseudoaneurysm formation,4 and
papillary muscle dysfunction or rupture.5 Since cross-sec-
tional echocardiography visualizes the cardiac apex directly6
where the majority of ischemia-related septal defects are
located,7 it has been extremely useful in diagnosis of post-
myocardial infarction ventricular septal rupture.8-10 We de-
scribe a case with ventricular septal defect complicating an
acute myocardial infarction, diagnosed by cross-sectional
echocardiography and confirmed by angiocardiography and
cardiac surgery.
CASE REPORT
The patient was a 61-year-old white female, transferred to
Saint Michael s Medical Center, Newark, for evaluation and
further management after she was admitted to a nearby
hospital with prolonged chest pain. Admission electrocardio-
grams and cardiac enzyme levels were consistent with an
extensive acute myocardial infarction (MI). She did well for
two days until the day prior to transfer, when she developed
transient atrial fibrillation, and was treated with digitalis and
furosemide. On the day of transfer, a harsh holosystolic
murmur was audible for the first time over the precordium
and was associated with a resting tachycardia of 122/min.
The patient’s past history was remarkable only for hyper-
tension, for which she had been on hydrochlorothiazide 25
mg daily for several years. There were no other known risk
factors for coronary artery disease. On evaluation, the
patient appeared to be comfortable in the supine positions
and afebrile. Pulse was regular at 95/min; blood pressure was
110/70 right arm; respirations were 18/min and unlabored.
Jugular venous pulse was not distended and there was no
peripheral edema. PMI was poorly felt; SI and S2 were soft;
S4 was present. A harsh grade III/VI holosystolic murmur
was audible at the left sternal border without any definite
radiation. Examination of the lungs, abdomen, and central
nervous system was unremarkable. An electrocardiogram
was consistent with a recent extensive anterior wall MI.
Portable chest roentgenogram revealed a possible left lower
lobe infiltrate. A bedside two-dimensional echocardio-
graphic study showed akinesis of the entire left ventricle (LV)
apex. The apical portion of the interventricular septum
consistently was absent in several views. This was best seen
on the apical four-chamber view (Figure 1 ). The free inferior
portion of the interventricular septum further appeared
bulbous suggesting marked edema. The LV and left atrium
(LA) also were enlarged. A Swan-Ganz catheter was inserted
percutaneously and revealed a step up at the right ventricle
♦From the Department of Cardiology, Saint Michael’s Medical
Center, Newark. Correspondence may be addressed to Dr. Agarwal,
Saint Michael s Medical Center, 306 High Street, Newark, NJ
07102.
110
VOL. 81— NUMBER 2— FEBRUARY 1984
gure 1 — Two-dimensional echocardiogram; apical four-
lamber view. Note the missing apical interventricular septum
,rrow). LV = left ventricle; RV = right ventricle; LA=left atrium;
A = rig ht atrium.
figure 2 — Coronary angiogram. Note the total occlusion of the
9ft anterior descending (LAD) artery (arrow). The left circumflex
irtery (LFC) appears clean.
Figure 3 — Left ventriculogram. The contrast is seen entering the
right ventricle (RV) when injected into the left ventricle (LV). Ao
= Aorta.
Figure 4 — The arrow points to the ventricular septal defect as
seen during surgery.
RV) level consistent with recirculation from the left heart to
[he right ventricle with a Qp/Qs ratio greater than 3:1. On
;ated acquisition of the blood pool scan, the LV was
lijinlarged greatly with akinesis of the entire anteroseptal
jijnferoapical wall. The LV ejection fraction was 17 percent.
Cardiac catheterization revealed a large anterior septal and
Epical infarction with total occlusion of the left anterior
(descending artery in its proximal position (Figure 2). A large
ventricular septal defect was recognized on left ventriculog-
■aphy (Figure 3). A guidewire mediated intraaortic balloon*
was inserted percutaneously and the patient was operated on
[the following morning. At surgery, a large apical ventricular
septal defect was confirmed. (Figure 4).
DISCUSSION
Ventricular septal rupture, a rare complication of acute
myocardial infarction, is a serious event11 with the majority
occurring within the first week after infarction.12 Clinical
recognition often is difficult13 but unremitting circulatory
deterioration14 may demand early surgery.13 Further, recent
data suggest an acceptable mortality (50 percent) with early
surgical intervention in the unstable patient versus unac-
ceptably high mortality (90 percent) with medical therapy of
afterload reduction and intraaortic balloon pump once shock
*Kontron Cardiovascular, Inc., Everett, Massachusetts.
ensues.16 Although cardiac catheterization may be performed
in critically ill patients,17 it imposes an increased risk.
Bedside Swan-Ganz catheterization does not allow the site or
size of the septal defect to be judged well.18 This information
is of importance to the surgeon.14
Several M-mode echocardiographic findings in ischemic
septal rupture have been described19'21 including dilatation of
the right ventricle, early mitral valve opening or abnormal
septal, and tricuspid valve motion. Rarely, septal discon-
tinuity may be recognized.22 Since these are nonspecific
findings, an accurate assessment of the myocardial damage is
lacking in this method.
Cross-sectional echocardiography, by providing spatial
orientation, allows direct visualization of isolated ventricular
septal defects.23 By using several acoustic windows, the entire
length of the interventricular septum can be viewed.24 Left to
right shunting may be inferred by negative contrast in the
right ventricle using intravenous contrast echocardiog-
raphy.23 Further, recognition of an associated septal
aneurysm or localization of the defect anteriorly or posterior-
ly easily can be made providing useful preoperative informa-
tion.14,26
It is important that several sweeps be made from apical to
basal and inferior to posterior areas to avoid a false negative
study. Although technical dropouts may occur, correct ad-
justments of gain characteristics usually will allow defects as
small as 5 mm to be visualized.27
VOL. 81— NUMBER 2— FEBRUARY 1984
A false positive study due to echo dropouts from technical
aberration should be excluded by recording the defect per-
sistently in the same location on at least two separate two-
dimensional views.
The most useful views have been parasternal short axis8
and apical four chamber.10’28 We recognized the defect best
in the apical four-chamber view.
Cross-sectional echocardiography has acquired an impor-
tant role in the evaluation of seriously ill patients with
complicated myocardial infarction. The case presented in
this report illustrates the quick, accurate, and hazard-free
capability of two-dimensional echocardiography in diagnos-
ing an acute postmyocardial infarction septa! rupture.
REFERENCES
1. Niscon JV, Narahara KA, Smitherman TC: Estimation of
myocardial involvement in patients with acute myocardial infarction
by two-dimensional echocardiography. Circulation 62:1248-1255,
1980.
2. Meltzer RS, Woythaler JN, Buda AJ, et al.: Two-dimensional
echocardiographic qualification of infarct size alteration by pharma-
cologic agents. Am J Cardiol 44:257-262, 1979.
3. Weyman AE, Peskoe SM, Welham ES, et al.: Detection of left
ventricular aneurysm by cross-sectional echocardiography. Circula-
tion 54:936-942, 1976.
4. Catherwood E, Mintz GS, Kotler MN, et al.: Two-dimensional
echocardiography recognition of left ventricular pseudo-aneurysm.
Circulation 62:294-303, 1980.
5. Fergenbaum H: Echocardiography, 3rd Edition. Philadelphia,
PA, Lea and Febiger, 1981, pp. 469.
6. Hickman HO, Weyman AE, Wann LS, et al.: Cross-sectional
echocardiography of the cardiac apex. Circulation 56:3:153, 1977.
7. Kaplan MA, Harris CN, Kay JH, et al.: Postinfarctional
ventricular septal rupture: Clinical approach and surgical results
Chest 69:734-738, 1976.
8. Scanlan TG, Seward JB, Tajrk AJ: Visualization of ventricular
septal rupture utilizing wide-angle two-dimensional echocardiog-
raphy. Mayo Clin Proc 54:381-384, 1979.
9. Farcot JC, Borsante L, Rigand M, et al.: Two-dimensional
echocardiographic visualization of ventricular rupture after acute
anterior myocardial infarction. Am J Cardiol 45:370-377, 1980.
10. Sanders RJ, Kern WH, Blount SG Jr: Perforation of the
interventricular septum complicating myocardial infarction Am
Heart J 81:736-748, 1956.
11. Giulian, ER, Danielson GK, Piuth JR, et al.: Postinfarction
ventricular septal rupture: Surgical considerations and results.
Circulation 49:455-459, 1974.
12. Dugall JC, Pryor R, Blount SG: Systolic murmur follow,
myocardial infarction. Am Heart J 87:577-583, 1974.
13. Kaplan MA, Harris CN, Kay JH, et al.: Postinfarctio |
ventricular septal rupture clinical approach and surgical resu
Chest 69:734-738, 1976.
14. Dagget WM, Guyton RA, Mundth E, et al.: Surgery ■
postmyocardial infarct ventricular septal defect Am S
186:260-271, 1977.
15. Bardet J, Masquet C, Kahn JC, et al.: Clinical £|
hemodynamic results of intraaortic counterpulsation and surgery
cardiogenic shock. Am Heart J 93:280-288, 1977.
16. Felner JM, Arenberg D, Meyer TP, Sympas PN, Schlant F
Ventricular septal rupture and mitral regurgitation in a patient w
an acute myocardial infarction. Chest 75:614-617, 1979,
17. Hill JD, Lary D, Kirth WJ, et al.: Acquired ventricular sep
defects. J Thorac Cardiovasc Surg 70:440-450, 1975.
18. Meister SG, Helfant RH: Rapid bedside differentiation
ruptured interventricular septum from acute mitral insufficiency
Engl J Med 287:1024-1025, 1972.
19. Chandraratra P, An-Balachandran PK, Shah PM, et J
Echocardiography observations on ventricular septal rupture co
plicating acute myocardial infarction. Circulation 51:506-510, 19'
20. De Joseph RL, Seides SF, Linder A, et al.: Echocardiograpl
findings of ventricular septal rupture in acute myocardial infarctic
Am J Cardiol 36:346-348, 1975.
21. Felner JM, Arenberg D, Meyer TP, et al.: Ventricular sep1
rupture and mitral regurgitation in patients with an acu,
myocardial infarction. Chest 75:614-617, 1979.
22. Kerin NJ, Edelstein J, DeRue RG: Ventricular septal defe
complicating acute myocardial infarction. Echocardiographic der
onstration confirmed by angiocardiograms and surgery Che
70:560-563, 1976.
23. Seward JB, Tayrk AJ, Hagler DJ, et al.: Visualization ,
isolated ventricular septal defect with wide-angle two-dimension
sector echocardiography. Circulation 2:202, 1978.
24. Tayrk AL, Seward JB, Hagler DJ, et al.: Two-dimension
real-time ultrasonic imagery of the heart and great vessels techniqu
image orientation, structure identification, and validation Max
Clin Proc 53:271-303, 1978.
25. Weyman AE, Wann LS, Hurwist RA, et al.: Negative contra:
echocardiography: A new technique for detecting left to right shun
Circulation 111:11-26, 1977.
26. Gerayr FJ, Schwartz MJ, Bell AL: Postmyocardial infarctio
ventricular septal tear syndrome. Chest 60:583-586, 1971.
27. King DL, Stieg CN, Ellis K: Visualization of ventricula
septal defects by cardiac ultrasonography. Circulation 48: 12 15-122(
28. Bishop HL, Gebson RS, Stann RB, et al.: Role of twc
dimensional echocardiography in the evaluation of patients wit!
ventricular septal rupture postmyocardial infarction. Am Heart ,
102:965-971, 1981.
112
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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rhe First Clinical Year o
Medical School
1ENRY KRANZLER, M.D., KEVIN VITTING, M.D.,
ICHARD C. REYNOLDS, M.D., Piscataway*
two medical students from UMDNJ-Rutgers Medical School kept
liaries during their third-year clerkships in medicine, surgery,
)ediatrics, obstetrics-gynecology, and psychiatry. An analysis of the
liaries provides a quantitative reflection on their experience and
nsight into their professional and personal maturation during this
period of their medical education.
For most students, the third year of
medical school is a series of clinical
clerkships exposing them to an en-
tirely new form of education and personal experience. Dur-
ing this year the focus of medical education is shifted from
j lectures, books, and classrooms to patients and hospitals.
The world of patient care makes new demands on the
“doctor-in-training,” who assumes an increasing amount of
'responsibility accompanied by anxiety. This also is a time
for the third-year student to explore future career op-
portunities and perhaps to select a specialty. It is a period
in which the student experiences a series of value conflicts
that commonly go unresolved. The student wants to spend
more time talking to patients, but is obligated to attend
rounds. He/she sees patients undergoing painful procedures
and, unsure of their appropriateness, is hesitant to question
their utility.
A number of personal accounts of the years spent in
medical school12 and of the internship year’ recently have
appeared. These are the latest contributions to a growing
literature on “the inner sanctum” of medical training and
practice.4 There also have been a number of reports which
have sought to document quantitatively the use of time by
medical students and residents,5 as well as by a variety of
medical practitioners.6 These studies have relied upon the
keeping of detailed diaries by the individuals involved.
This report combines quantitative observations with per-
sonal accounts and reflections on the third year of medical
school. The material which follows is derived from diaries
kept during the third year at UMDNJ-Rutgers Medical
School (RMS).
METHODS
Rutgers Medical School has a traditional four-year cur-
riculum. During the first two years, the student becomes
familiar with the science of medicine, studying anatomy,
physiology, pharmacology, biochemistry, microbiology, and
pathology. He/she is exposed briefly to statistics,
epidemiology, ethics, and selected topics in health economics
and health care delivery. Near the end of the second year,
in a course entitled, “Introduction to Clinical Medicine,” the
student learns the skills required for examining patients. The
third year consists of 48 weeks of major clinical clerkships
in pediatrics, psychiatry, and obstetrics-gynecology (8 weeks
each) and in medicine and surgery (12 weeks each). These
are offered at the major teaching hospital and affiliated
institutions. Individual student schedules are formulated
through a computerized matching system. The fourth year
of medical school is largely a series of electives on various
clinical services, except for obligatory rotations in family
medicine (4 weeks), neurology (2 weeks), and ophthalmology
and otolaryngology (1 week each).
The authors met several times prior to the third year to
plan the format of the diaries, as well as to discuss expecta-
tions of the upcoming year. Throughout the third year of
medical school, the authors met monthly to discuss the en-
*Dr. Reynolds is Dean, UMDNJ-Rutgers Medical School. Dr.
Kranzler is a psychiatric resident. University of Connecticut. Dr.
Vitting is a medical resident, Lenox Hill Hospital, New York. This
paper was written while Drs. Kranzler and Vitting were medical
students at UMDNJ. Correspondence may be addressed to Dr.
Reynolds, UMDNJ-Rutgers Medical School, P.O. Box 101,
Piscataway, NJ 08854.
113
VOL. 81— NUMBER 2— FEBRUARY 1984
tries. Once the year ended, the authors continued to meet
in order to develop a summary of the experience and to
assess the impact of the diary and discussions on that ex-
perience.
RESULTS
The results of the year-long personal review of the clinical
clerkships are two kinds: quantitative and subjective.
Table I depicts the character of the individual clerkship.
Student assignments to major clinical disciplines at RMS are
comparable to other medical schools.7 Within each student
clerkship at RMS there is considerable similarity. Each
clerkship is structured to include some didactic instruction.
For example, the faculty of obstetrics-gynecology provides
an extensive syllabus to the student and introduces the 8-
week clerkship with 1 week of formal instruction. The 12-
week medical clerkship includes a series of lectures on com-
mon medical problems.
The clinical clerkships are conducted in hospitals affiliated
with RMS. Currently, Middlesex General-University Hospi-
tal is the primary teaching hospital of RMS and most stu-
dents have a significant portion of their clerkships at this
institution. Clerkships also are conducted at St. Peter’s
Medical Center, New Brunswick, The Medical Center at
Princeton, and Muhlenberg Hospital, Plainfield. Psychiatric
clerkships also use the Institute of Mental Health Sciences,
Piscataway, and the Carrier Clinic, Belle Mead.
Table 2 provides the number of patients we actually exam-
ined during our third year of medical study. Other patients
were seen and discussed at rounds, but we were involved in
the care of the patients listed. We also have recorded the
major procedures in which we participated during clerkships.
T here are little data to compare our clinical experiences with
students enrolled in other schools.
The personal reflections from this year-long experience
will be described.
Kranzler: I approached my third year of medical school
with trepidation. I was concerned about being able to toler-
ate long hours, let alone function effectively with too little
sleep. I was reluctant to become involved with the keeping
of a journal, fearful that further demands on my time would
detract from my personal life.
Nonetheless, I began the year with gusto. Pediatrics
proved an ideal jumping-off point, for I enjoy children im-
mensely. However, my earliest entries in the journal were to
the point and involved little reflection, which I suspect was
equally true of my performance on the ward. The following
entry is illustrative: Tn the afternoon a 16-month-old girl was
admitted for extreme hyperactivity, unwillingness to eat, and
inability to sleep. The working diagnosis was that of toxic
ingestion. After the child was taken to her room, her mother
told me that she had to return home for a while to attend
to her other child I suggested that she carefully search her
house for a clue regarding the substance apparently ingested
by her daughter. She returned about an hour later with a
vial of Cylert, a stimulant which had been prescribed for a
neighbor’s child. Given this information we were able to give
the child chloral hydrate, which we had been reluctant to
do for fear that she had ingested phenobarbital, a medication
that had been prescribed for her father (September 11,
1980). Though I was proud of having intervened success-
fully, the above description gave no hint of that fact.
As time passed and I became more confident in my role,
my entries more accurately reflected my feelings, though I
still strove faithfully to document what I saw and heard. One
TABLE 1
Weeks in
Clinical Clerkships
Clerkship
Weeks
KV
HK
Pediatrics
Lectures
1
1
Inpatient
3 Vi
3 Vi
Outpatient & Nursery
3 Vi
3 Vi
Psychiatry
Adult
8
4
Adolescent
0
4
Obstetrics-Gynecology
Lectures
1
1
Clinical Work
7
7
Medicine
12
12
Surgery
General Surgery
6
6
Orthopedics
2
2
Urology
2
2
Anesthesia
1
1
Plastic Surgery
1
0
issue that 1 considered repeatedly as I wended my wa
through the maze of medical specialties was the proper rol
of technology in medical care. My first encounter with open
heart surgery prompted me to write the following: 'Th
environment in the operating room (OR) is technology a
its unrestrained best. With the addition of some cardiai
monitoring equipment and a heart-lung machine, the roorr
became all the more mechanically surreal. The operation wa:
well underway before these feelings of mine gave way tc
intense concentration on the specifics of the procedure. Tht
pop music in the background prompted dance-like move-
ments on the resident’s part, and at times he and the scrut
nurse appeared to be almost dancing together as they movec
to the music. Suddenly, a McDonald’s commercial came
blaring from the wall, and this, in the present context and
mixed in my mind with earlier news comments concerning
the attempted assassination of President Reagan, created a
montage of America in the 1980s that was at once both
curious and frightening. Though I wanted to share my
thoughts with the others at the table, I suspected that they j
would not be receptive to my thinking aloud and I sup-
pressed the urge. I refocused my attention on the now quiver-
ing mass of cardiac muscle which lay before me, buoyed in ,
a sea of blood (March 31, 1981).’
Earlier in the year it had become apparent to me that the
wonders wrought by medical technology often required that
a price be paid: 'I watched amniocentesis performed on a
35-year-old black woman, for the purpose of genetic screen- '
ing. The whole event was disturbing and it angered me
because the woman was very frightened and she began crying
and chanting in a foreign language. I later asked her where
she was from and realized, when she said she was from West
Africa, just how strange and culturally alien the whole ex- |
perience must have been for her. It was at this point that
I realized that my anger was due to the lack of concern for
this person s psychic well-being that the people “caring” for
her had demonstrated. Though some effort was made to
calm her, it was apparent that she had not been prepared
adequately beforehand. The sight of a half-dozen white
people in white coats surrounding her and about to violate
I 14
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 2
Number of Patients in Student Clerkship Experience
Patients Studied1 or
KV
Followed2
HK
Major Procedures
Pediatrics
Inpatients studied:’
8
11
Cesarean
followed:2
3
6
sections
Clinic Visits— illness:
12
17
routine:
Newborn examinations:
15
many
9
Psychiatric
Adults studied:
6
10
Electroconvulsive
followed:
24
4
therapy
Adolescents studied:
0
10
Cerebral Dysfunction Clinic
0
4
Child Evaluation Conference:
0
1
Obstetrics-Gynecology
Inpatients studied:
29
31
Operations:
followed:
6
6
Deliveries
Outpatients seen— Gyn
18
11
Vaginal:
Ob
26
30
Cesarean:
Amniocenteses:
Medicine
Inpatients studied:
27
28
followed:
17
10
Outpatients seen:
0
3
Surgery
Inpatients studied:
40
15
Operations
followed:
many
Assisted:
Outpatients seen:
4
56
Observed:
’Patients “studied” received a complete history and physical
examination and were followed with
2Patients “followed” were seen
regularly but only during part of their hospital stay.
KV HK
10
21
15
8
2
87
8
16
11
7
4
42
17
Iier pregnant abdomen with a long needle was a virtual
nightmare for her (January 22, 1981).’
As the year passed and I became more competent and
Comfortable in my role as a third-year medical student. I
began to welcome the time I would spend each evening
■chronicling the day’s events. I also looked forward to our
'monthly meetings, at which time we discussed our different
experiences and the feelings they aroused. Eventually I re-
alized that the journal and meetings enhanced my medical
education by requiring that I reflect critically on my ex-
perience and by providing me with an opportunity to discuss
my feelings with a fellow student and a senior faculty mem-
ber.
Immersion in a strange environment, combined with
stringent demands on one’s time and energy, can result in
feelings of panic and distraction. The continuity provided me
by my regular journal entries contributed enormously to my
perception that the many parts of specialized medicine do,
in fact, comprise a unified whole. More than simply integrat-
ing experiences, the journal and monthly meetings provided
me with an opportunity to make explicit many of the un-
spoken rules of clinical medicine and hospital conduct.
Vitting: My third year of medical school was more than
a first pass with the many caricatures of disease — it was a
challenge daring me to assume the role of the clinician. To
do this required not only a conceptual and empirical data
base, it depended on role models and a setting in which to
imitate them.
I soon discovered that the character of my relationships
with patients depended on my knowledge and experience in
addressing what ailed them. At first, whenever I felt that they
knew more than I did about their own diseases, I feared that
my questions would betray my naivete.' This was especially
true in psychiatry. Sometimes a weary patient would ask me
to go learn on someone else; usually, though, the barrier was
a silent one. But, as my expertise and assertiveness mounted,
I addressed an expanding repertoire of disease with increas-
ing ease. Eventually, even very highly educated, private pa-
tients accepted my intrusion as necessary and beneficial to
them as well as to me.
The impediment that I faced with some patients was
characteristic of the environment of Rutgers Medical School.
Unlike the circumstances at many established urban medical
centers, most of our patients were highly educated and pri-
vate. And they knew that medical students were not neces-
sary for their care. The newness of our school itself presented
another obstacle, for some patients and hospital staff were
used to years of nonacademic medicine and did not see why
this had to change. But our suburban setup did confer some
benefits in that we studied in settings typical of those in
which most of us someday will practice.
With time, my interaction with patients improved, as did
my recording of their histories and physicals and both came
to be motivated by a spirit of curiosity rather than a yearning
for completeness. I began to know many of my patients as
friends. Their clinical revelations enabled me to become fully
involved in their care and, I hope, to add to the quality of
care provided by those in charge. In this way, most patients
VOL. 81— NUMBER 2— FEBRUARY 1984
I 15
came to appreciate my participation in their care.
The teaching by the clinical faculty at RMS was
enthusiastic. Most attendings took pains to be punctual and
to emphasize what was important in their lectures and
rounds. They shared their patients and techniques with me.
I gave them a platform at the bedside for professing their
art. They supported my fragile role as a fledgling clinician
by trusting my findings and addressing me as “doctor.”
I was initiated into the ancient rite of attending rounds
early in pediatrics: ‘I found that the demands of the attend-
ings on rounds sometimes are hard to predict. At any point
they might divert you and you may have to pick up and talk
about any one detail while not losing your place in the
presentation. You must appreciate the digressions, however,
for they are almost always enlightening and memorable (Oc-
tober 7, 1980).’
By the time I finished my rotation in medicine my attitude
had matured: ‘I enjoyed the internists who derived great
pleasure from recounting old clinical tales that contain a
twist or a moral. They share the best cases collected over
a lifetime, pouring them out like vintage wines, tasting them,
and recorking them for the next time. And they love to hear
the students presenting patients, provided that they take the
pains to ensure accuracy and coherence (April 23, 1981).’
“Sometimes a weary patient would
ask me to go learn on someone
else; usually, though, the harrier
was a silent one.”
Another great tradition in which we participated was the
oral examination, which is a natural and spontaneous ex-
tension of attending rounds. I felt it served as a much truer
assessment of my abilities than did our written multiple-
choice exams.
My interaction with the house staff was variable. Some
of them were highly enthusiastic, humane, and instructive.
With most of them I had an understanding that they would
help me interpret the cases and learn what is really important
if I would write the progress notes and do most of the routine
procedures.
Being accessible, the residents served as more immediate
role models than did the attendings. Some were exceptionally
gallant and courteous to patients; some would skip seeing
them and write down, WNL. Some were abrupt and callous
toward patients and would even scorn me for stopping to
talk to them. Some derided any patient who could not speak
for himself: ‘I find myself sometimes drifting into the resi-
dents’ detachment. It seems we can speak more freely in the
elevators when there are no laymen around, and when we
turn a corner and walk through a gathering of worried
relatives outside the ICU, we have to remember to resume
a serious expression, reminding ourselves of the grave nature
of our work. It is essential for the people to respect our work.
And it is equally imperative for us to respect our work (April
2, 1981).’
I encountered a more altruistic spirit among the ancillary
personnel— nurses, technicians, and social workers— who
still seemed to react to the ravages of disease through the
same eyes as its victims.
An important facet ot my third-year experience was my
clinical diary. At times, for the sake of the diary, I felt
compelled to make time for my own rounds with patients.
at which time I got to know their personalities and the
illnesses on a more personal level and to record informatie
about them for further reflection. From these anecdot
there became a forum for my triumphs and frustration
from which emerged a choice of career and a standard <
medicine.
Reynolds: As dean of the medical school I encouraged tu
students to keep diaries and meet with me regularly to di
cuss their clerkship experiences. I was interested in exact
what took place in a clerkship: How many patients did
student actually examine on each clerkship? How muc
didactic teaching occurred? How was the student actual
involved in patient care? How many hours did the studei
spend in the hospital? Most of these questions represente
a quantitative description of the clerkship, information thf
surprisingly is difficult to find. In addition, I was curioi
to try to understand how the student felt about the third yes
of medical school. Most of us generalize from our earl,
clinical experiences and too commonly make pronounci,
ments and decisions from this point of reference. How doe
the clinical maturation of medical students take place? Ho'
anxious is the student who begins a clerkship today? Whs
exaggerates the uneasiness? How is stress handled?
The regular meetings with the two students helped t
bridge the gap between the administrative and educations
processes. Medical schools now are complicated, sophist!
cated institutions with many employees and large budget;
It is all too easy for the dean of the medical school to becom
detached from the education of medical students, the majo
purpose of the school, and to have no personal under
standing of their problems. Communication with medica
students unfortunately is a task too often neglected by medi
cal school administrators.
Reading regularly the diaries and meeting monthly witl
the students did give me more knowledge and insight int(
the third-year clerkship experience. For the first time, I hat
a detailed record of two students' experiences which prob
ably are representative of students in the third year at RMS
Of equal importance were the subjective analyses by thes<
students of their own clerkships.
Early in our discussions it was necessary to decide tha
all remarks were made in confidence. It was not possible foi
students to comment on their clerkships without a mixtun
of laudatory and derogatory remarks about faculty and pri-
vate attending physicians and hospitals. I also shared with
the students my observations on the clinical education pro-
cess at Rutgers Medical School. I soon began to understanc
from the student's perspective the fear of looking stupid,
intimidation early in the clerkship by nearly everyone includ-
ing nurses and technicians as well as faculty, and the required:
commitment of hours and weeks during the successive
clinical experiences.
I did not readily accept the students' complaints; they did
not always agree with my explanations for some of their less
than pleasant experiences. Unquestionably, we all profited
from the exchange.
CONCLUSION
Kranzler and Vitting: During the third year of medical
school, the maturation of our clinical skills followed a pre-
dictable course, which is memorable to every physician. The
year was replete with new experiences and pressures. It de-
manded a substantial change in self-image. We came to
appreciate our patients as something more than complex
biological systems. By providing an opportunity for reflec-
1 16
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
n, our journals and regular discussions enhanced both our
||)fessional and personal development.
Though we recorded comparable numbers of clinical en-
jnters in similar settings, it is interesting to note the dif-
ence in emphasis in our separate discussions. While one
us was concerned with the impact of technology on the
ictice of medicine, the other focused on his own maturing
ationships with patients and physicians. Our essays reflect
r differing backgrounds and temperaments. They comple-
:nt each other to form a students' perspective on the first
nical year of medical school.
iFinally, keeping a journal has enabled us to compile an
curate account of the clinical exposure gained in the con-
ct of a traditional third year. We expect that this enumer-
on will stimulate efforts to define further this pivotal year
medical education.
Reynolds: The process of meeting regularly with two in-
ligent, sensitive medical students and discussing with them
eir diary entries during the year of clinical clerkships gave
me far more insight into this phase of medical education than
the review of faculty program descriptions and student evalu-
ations. I experienced the concomitant pleasure of watching
two young medical students achieve clinical maturity as they
progressed through their third year of medical school.
REFERENCES
1. Klein K; Getting Better: A Medical Student's Story. Boston,
MA, Little, Brown and Co., 1981.
2. LeBaron C: Gentle Vengeance. New York, NY, Richard
Mareck, 1981.
3. LaPalio LR. Time study of students and house staff on a
university medical service. J Med Educ 56:61-64, 1981.
4. Shem S: The House of God. New York, NY, Dell, 1978.
5. Borgenicht L: American medicine: An annotated bibliography.
N Engl J Med 304:1112-1117, 1981.
6. Mendenhall RC, Lloyd JS, Repicky PA, Monson JR, Girard
RA, Abrahamson S: A national study of medical and surgical
specialties: II. Description of the survey instrument. JAMA
240:1160-1168, 1978.
7. AAMC Curriculum Directory: 1982-83, Washington, D.C.
)L. 81— NUMBER 2— FEBRUARY 1984
1 17
Treatment with Navane can produce improvement in
psychotic symptoms such as hallucinatory behavior and
unusual thought content as well as hostility, disorientation
and depressive mood,1 2 leaving the elderly patient more
alert2 and better able to participate in the activities of
g, 5 mg, 10 mg, 20 mg
il Intramuscular 2 mg/ml, 5 mg/ml
A division of Hizer
Navane
(thiothixene) (thiothixene HCI)
References 1. Util TM, Unverdi C. Wohlrade J, et al: Drug therapy of psychosis associated with
organic brain syndrome. Presented as a Scientific Exhibit at the American Public Health Associa-
tion Centennial, Atlantic City, New Jersey, November 12-16, 1972, 2. Katz MM, Util TM: Video
methodology for research in psychopathology and psychopharmacology. Arch Gen Psychiatry
31:204-210, 1974. 3. Ketai R: Psychotropic drugs in the management of psychiatric emergencies.
Postgraduate Medicine 58:87-93, 1975. 4. Birkett DR Hirschfield W, Simpson GM Thiothixene in
the treatment of diseases of the senium. CurrTherRes 14:775-779, 1972. 5. Data on file at Roerig
BRIEF SUMMARY OF PRESCRIBING INFORMATION
Navane® (thiothixene) Capsules: 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
(thiothixene hydrochloride) Concentrate: 5 mg/ml, Intramuscular: 2 mg/ml, 5 mg/ml
Contraindications: Navane (thiothixene) is contraindicated in patients with circulatory collapse,
comatose states, central nervous system depression due to any cause, and blood dyscrasias!
Navane is contraindicated in individuals who have shown hypersensitivity to the drug. It is not
known whether there is a cross-sensitivity between the thioxanthenes and the phenothiazine
derivatives, but the possibility should be considered.
Warnings: Usage in Pregnancy -Safe use of Navane during pregnancy has not been established.
Therefore, this drug should be given to pregnant patients only when, in the judgment of the
physician, the expected benefits from the treatment exceed the possible risks to mother and fetus.
Animal reproduction studies and clinical experience to date have not demonstrated any
teratogenic effects.
In the animal reproduction studies with Navane, there was some decrease in conception rate
and litter size, and an increase in resorption rate in rats and rabbits, changes which have been
similarly reported with other psychotropic agents. After repeated oral administration of Navane to
rats (5 to 15 mg/kg/day), rabbits (3 to 50 mg/kg/day), and monkeys (1 to 3 mg/kg/day) before and
during gestation, no teratogenic effects were seen, (See Precautions.)
Usage in Children- The use of Navane in children under 12 years of age is not recommended
because safety and efficacy in the pediatric age group have not been established.
As is true with many CNS drugs. Navane may impair the mental and/or physical abilities required
for the performance of potentially hazardous tasks such as driving a car or operating machinery
especially during the first few days of therapy. Therefore, the patient should be cautioned accord-
ingly.
As in the case of other CNS-acting drugs, patients receiving Navane should be cautioned about
the possible additive effects (which may include hypotension) with CNS depressants and with
alcohol.
Precautions: An antiemetic effect was observed in animal studies with Navane, since this effect
may also occur in man, it is possible that Navane may mask signs of overdosage of toxic drugs and
may obscure conditions such as intestinal obstruction and brain tumor.
In consideration of the known capability of Navane and certain other psychotropic drugs to
precipitate convulsions, extreme caution should be used in patients with a history of convulsive
disorders or those in a state of alcohol withdrawal since it may lower the convulsive threshold
Although Navane potentiates the actions of the barbiturates, the dosage of the anticonvulsant
therapy should not be reduced when Navane is administered concurrently.
Caution as well as careful adjustment of the dosage is indicated when Navane is used in
conjunction with other CNS depressants other than anticonvulsant drugs
Though exhibiting rather weak anticholinergic properties, Navane should be used with caution
in patients who are known or suspected to have glaucoma, or who migfit be exposed to extreme
heat, or who are receiving atropine or related drugs.
Use with caution in patients with cardiovascular disease.
Also, careful observation should be made for pigmentary retinopathy, and lenticular pigmenta-
tion (fine lenticular pigmentation has been noted in a small number of patients treated with Navane
for prolonged periods) Blood dyscrasias (agranulocytosis, pancytopenia, thrombocytopenic
purpura), and liver damage (jaundice, biliary stasis) have been reported with related drugs.
Undue exposure to sunlight should be avoided. Photosensitive reactions have been reported in
patients on Navane.
Neuroleptic drugs elevate prolactin levels; the elevation persists during chronic administration
Tissue culture experiments indicate that approximately one-third of human breast cancers are
prolactin dependent in vitro, a factor of potential importance' if the prescription of these drugs is
contemplated in a patient with a previously detected breast cancer. Although disturbances such
as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the clinical
significance of elevated serum prolactin levels is unknown for most patients. An increase in
mammary neoplasms has been found in rodents after chronic administration of neuroleptic drugs
Neither clinical studies nor epidemiologic studies conducted to date, however, have shown an
association between chronic administration of these drugs and mammary tumorigenesis the
available evidence is considered too limited to be conclusive at this time.
Intramuscular Administration- As with all intramuscular preparations, Navane Intramuscular
should be injected well within the body of a relatively large muscle. The preferred sites are the
uppf 1 r outer quadrant of the buttock (i.e. gluteus maximus) and the mid-lateral thigh.
The deltoid area should be used only if well developed, such as in certain adults and older
children, and then only with caution to avoid radial nerve injury. Intramuscular injections should not
be made into the lower and mid-thirds of the upper arm. As with all intramuscular injections
aspiration is necessary to help avoid inadvertent injection into a blood vessel.
Adveree Reactions: Note: Not all of the following adverse reactions have been reported with
Ho^ever since Navane has certain chemical and pharmacologic similarities
to the phenothiazines, all of the known side effects and toxicity associated with phenothiazine
therapy should be borne in mind when Navane is used.
Cardiovascular effects: Tachycardia, hypotension, lightheadedness, and syncope In the event
ypotens'on occurs epinephrine should not be used as a pressor agent since a paradoxical
Inmo n^Ver!n9 ° blood pressure may result. Nonspecific EKG changes have been observed in
some patients receiving Navane. These changes are usually reversible and frequently disappear
snmp nhn0UelNaVane Tif^' Th® lncidence of ,hese changes is lower than that observed with
^oPh« hlaZlnes The cllnlcal Sl9nif'cance of these changes is not known
of Nalne^hemnvThpInPiH Sually ?lldhmay occur a'though it usually subsides wtih continuation
“!Nav?hne the,apy- The incidence of sedation appears similar to that of the piperazine qroup of
«nm^ h'neShbU es® taan that of certain al'Phatic phenothiazines. Restlessness, agitation and
lav® been n°ted Wlth Navane (thiothixene). Seizures and paradoxical exacerbation of
psychotic symptoms have occurred with Navane infrequently
relatePdedreufgsXia ^ rep0rted 'nfantS delivered from mothers havin9 received structurally
brospinai'fluKf SrSes* denVa,'VeS *** ^ W,th Cerebral edema and cere-
Ext,ra5y^midal sympt°ms' such as pseudo-parkinsonism, akathisia, and dystonia have been
p p° ded, Management of these extrapyramidal symptoms depends upon the type and severity.
Rapid relief of acute symptoms may require the use of an injectable antiparkinson agent More
tehng^n oe^an.fpYaTkPn°son agem" ma"a9ed by redUC'n9 the d°Sa9e °' Navane and/or adminis'
Persistent Tardive Dyskinesia: As with all antipsychotic agents tardive dyskinesia may appear in
some patients on long term therapy or may occur after drug therapy has been discontinued. The
risk seems to be greater in elderly patients on high-dose therapy, especially females The symp-
K°mK a.Le per*ls,en,t and in some Patients appear to be irreversible. The syndrome is characterized
by rhythmical involuntary movements of the tongue, face, mouth or jaw (e g., protrusion of tonque
puffing of cheeks, puckering of mouth, chewing movements). Sometimes these may be accom-
panied by involuntary movements of extremities.
Capsules
available in
5 strengths
1 mg
JKr
2 mg
5 mg
10 mg
WBMft HUMG i
Mm “
Concentrate
5 mg/ml
! NDC 0049-5750-51
I Navane
j ^othixene HCI
Intramuscular
2 mg/ml
5 mg/ml
There is no known effective treatment for tardive dyskinesia, antiparkinsonism agents usufjl
not alleviate the symptoms of this syndrome. It is suggested that all antipsychotic ageril
discontinued if these symptoms appear
Should it be necessary to reinstitute treatment, or increase the dosage of the agent, or switc.,|
different antipsychotic agent, the syndrome may be masked.
It has been reported that fine vermicular movements of the tongue may be an early sign ..II
syndrome and if the medication is stopped at that time, the syndrome may not develop. j
Hepatic effects: Elevations of serum transaminase and alkaline phosphatase, usually trar |
have been infrequently observed in some patients. No clinically confirmed cases of jaujl
attributable to Navane (thiothixene) have been reported.
Hematologic effects: As is true with certain other psychotropic drugs, leukopenic I
leukocytosis, which are usually transient, can occur occasionally with Navane. Other antipsyc I
drugs have been associated with agranulocytosis, eosinophilia, hemolytic anemia, ti i
bocytopenia and pancytopenia.
Allergic reactions: Rash, pruritus, urticaria, photosensitivity and rare cases of anaphylaxis
been reported with Navane. Undue exposure to sunlight should be avoided. Although note;
enced with Navane, exfoliative dermatitis and contact dermatitis (in nur.sing personnel) have
reported with certain phenothiazines.
Endocrine disorders. Lactation, moderate breast enlargement and amenorrhea have occ
in a small percentage of females receiving Navane. If persistent, this may necessitate a redi
in dosage or the discontinuation of therapy. Phenothiazines have been associated with
positive pregnancy tests, gynecomastia, hypoglycemia, hyperglycemia, and glycosuria.
Autonomic effects. Dry mouth, blurred vision, nasal congestion, constipation, increased si
ing, increased salivation, and impotence have occurred infrequently with Navane the
Phenothiazines have been associated with miosis, mydriasis, and adynamic ileus.
Other adverse reactions: Hyperpyrexia, anorexia, nausea, vomiting, diarrhea, increase in a
tite and weight, weakness or fatigue, polydipsia and peripheral edema.
Although not reported with Navane, evidence indicates there is a relationship betv
phenothiazine therapy and the occurrence of a systemic lupus erythematosus-like syndromi
NOTE Sudden deaths have occasionally been reported in patients who have received ce
phenothiazine derivatives. In some cases the cause of death was apparently cardiac arre
asphyxia due to failure of the cough reflex. In others, the cause could not be determined nor c
it be established that death was due to phenothiazine administration.
Dosage and Administration: Dosage of Navane should be individually adjusted depending o
chronicity and severity of the condition In general, small doses should be used initially
gradually increased to the optimal effective level, based on patient response.
Some patients have been successfully maintained on once-a-day Navane therapy.
Usage in children under 1 2 years of age is not recommended because safe conditions for its
have not been established.
Navane Intramuscular Solution Navane For Injection —Where more rapid control and treatr
of acute behavior is desirable, the intramuscular form of Navane may be indicated. It is als
benefit where the very nature of the patient's symptomatology, whether acute or chronic rem
oral administration impractical or even impossible.
For treatment of acute symptomatology or in patients unable or unwilling to take oral medica j
the usual dose is 4 mg of Navane Intramuscular administered 2 to 4 times daily. Dosage ma !
increased or decreased depending on response Most patients are controlled on a total c
dosage of 16 to 20 mg. The maximum recommended dosage is 30 mg/day. An oral form shi.j
supplant the injectable form as soon as possible. It may be necessary to adjust the dosage w j
changing from the intramuscular to oral dosage forms. Dosage recommendations for NaC
(thiothixene) Capsules and Concentrate appear in the following paragraphs.
Navane Capsules: Navane Concentrate - In milder conditions, an initial dose of 2 mg three tii ’
daily If indicated, a subsequent increase to 15 mg/day total daily dose is often effective I
In more severe conditions, an initial dose of 5 mg twice daily.
The usual optimal dose is 20 to 30 mg daily. If indicated, an increase to 60 mg/day total ci
dose is often effective. Exceeding a total daily dose of 60 mg rarely increases the benef I
response.
Overdosage. Manifestations include musculartwitching, drowsiness, and dizziness. Symptorr j
gross overdosage may include CNS depression, rigidity, weakness, torticollis tremor salivat
dysphagia, hypotension, disturbances of gait, or coma.
Treatment. Essentially is symptomatic and supportive. For Navane oral, early gastric lavag j
helpful. For Navane oral and Intramuscular, keep patient under careful observation and main j|
an open airway, since involvement of the extrapyramidal system may produce dysphagia .1
respiratory difficulty in severe overdosage. If hypotension occurs, the standard measures:
managing circulatory shock should be used (I.V fluids and/or vasoconstrictors.)
If a vasoconstrictor is needed, levarterenol and phenylephrine are the most suitable driSI
Other pressor agenjs, including epinephrine, are not recommended, since phenothiazine der
tives may reverse the usual pressor action of these agents and cause further lowerinq of the bid
pressure.
If CNS depression is present and specific therapy is indicated, recommended stimulslj
include amphetamine, dextroamphetamine, or caffeine and sodium benzoate. Stimulants tjl
may cause convulsions (e g picrotoxm or pentylenetetrazol) should be avoided. Extrapyrami ;j
symptoms may be treated with antiparkinson drugs
There are no data on the use of peritoneal or hemodialysis, but they are known to be of little vai
in phenothiazine intoxication.
ROeRIG<@
A division of Pfizer PharmaceuticJ
;
120
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY!
[s There an Indigenous
Viral Flora in Man?
FRANK J. MICHALSKI, Ph.D., Newark*
Does man have a normal viral flora in the same way that he has a
bacterial flora? Although pertinent data are scarce, available data
suggest a negative response. Many types of viruses can be found in
the human body; so far, no symbiotic function as occurs with bacteria
has been shown.
The question of a viral flora has been
asked by physicians and medical
students during lectures on the
diagnosis of viral infections in humans. A computer search
of the literature revealed no papers specifically addressed to
this question. Isenberg and Painter stated discussion of virus
carriage in healthy individuals has been omitted because of
the paucity of pertinent information.' In this paper, an
attempt will be made to document the data available and
to answer this intriguing question.
Indigenous is defined as produced, growing, or living
naturally in a particular region or environment. Another
word with a slightly different meaning that sometimes is used
instead of indigenous is endogenous, which means growing
on the inside or originating within the body. As applied to
bacteriology, these definitions have a twofold meaning. One
is the location in or on the human body and the second is
an implied lack of harm due to their presence, i.e. living
naturally. Almost every microbiology textbook contains a
chapter1'4 on indigenous bacteria in humans: “The body of
man becomes infected from the moment of birth, and a
variety of species establish a more or less permanent
residence on or even in the superficial tissue. Here, they
usually are symbiotic and benefit the host in a number of
ways. Some of their actions however, may not be beneficial,
and when the general resistance of the host is sufficiently
depressed they may even cause disease.'”
Infection with viruses may take place at birth, such as the
highly lethal neonatal herpes simplex infection, or even
before birth as congenital rubella or cytomegalovirus (C MV)
infection. The consequence of most of these acute, lytic-
virus infections is disease of varying severity. Another type
of virus infection not as greatly researched and written about
is the persistent virus infection which, in some cases, can
cause disease without any apparent cytopathology.5 There-
fore, in contrast to bacteria, most viral infections are not
symbiotic and do not benefit the host. So, the term
indigenous as applied to bacteria may not apply to viruses
in the second meaning as being helpful. In the other meaning,
viruses may be found in the body and this usually is referred
to as persistent or latent infections.
Much has been written about persistent or latent virus
infections and many definitions have been brought forward.
Melnick defines latent virus infection as viral persistence in
the absence of clinical symptoms.6 The virus might or might
not be in a proviral or a negative state, and virus particles
might or might not be produced. Rapp defines persistent
infection as one in which infectious virus continually is
released even in the presence of circulating antibody and in
the absence of symptoms of disease.7 A latent infection is
one in which at least the genome of the virus is present, but
infectious viruses cannot be recovered except during episodes
of overt disease. So, with reference to infection with viruses,
the term persistent or latent would be better than the term
indigenous as used for bacteria.
Almost all types of animals that have been used for virus
research have been found to harbor latent, indigenous, or,
as it often is referred, endogenous viral flora.814 These
include chickens, mice, rats, rabbits, hamsters, dogs, cats,
guinea pigs, and monkeys. The fact that these animals harbor
*Dr. Michalski is affiliated with the Diagnostic Virology Labora-
tory, Saint Michael’s Medical Center. Correspondence may be
addressed to Dr. Michalski, Saint Michael's Medical Center, 268
High Street, Newark, NJ 07102.
VOL. 81— NUMBER 2— FEBRUARY 1984
121
numerous types of indigenous viruses would seem to make
it likely that man also harbors indigenous viruses. So far,
testing of human tissues has found few viruses which would
be considered indigenous.1' There are viruses in the human
body, in some circumstances, that could be considered
indigenous. These viruses can be isolated or identified using
either standard diagnostic virology methods or special
biochemical techniques. Some could be considered as
persistent infections with virus shedding for long periods
and, in some, the virus can be reactivated from a latent stage
somewhere in the body.
If you search a human body for viruses at a time of no
overt illness, what viruses might you find? The Table shows
a list of possible candidates for human indigenous viruses
grouped by type of nucleic acid, either DNA or RNA. This
list does not pretend to be inclusive and other viruses yet
to be discovered may have to be added later.
First on the list is hepatitis B because the virus sometimes
can remain in the blood for years after primary infection as
a chronic persistent infection in the absence of overt dis-
ease.lf,IH This virus causes clinical serum hepatitis, but
sometimes there is liver damage leading to cirrhosis or even
carcinoma. The virus sometimes can be found in the liver
and in the urine. Since the virus cannot be grown in cell
culture, diagnosis relies on the detection of antigen or
antibody by serodiagnostic methods such as radioimmune
assay (RIA) or enzyme linked immunosorbent assay
(ELISA). The body responds to infection with production
of antibodies to the various antigens of hepatitis B, namely
hepatitis B surface antigen (Hbs Ag), hepatitis B core antigen
(Hbc Ag), or hepatitis B e antigen. Some of these antibodies
can persist for life and in some populations 5 to 20 percent
of healthy adults have antibody to HBSAg. Posttransfusion
hepatitis primarily is carried by non-A, non-B hepatitis virus.
Much research now is in progress on the non-A, non-B
hepatitis virus, but preliminary results suggest it may be
similar to hepatitis B.
BK and JC, members of the papovavirus family, were put
on the list because they can be reactivated from latency in
an unknown part of the body; they are found in the urine
of immunosuppressed patients, especially those with renal
transplan ts.142" The only disease associated with these viruses
is progressive multifocal leukoencephalopathy (PML). JC
virus has been isolated from brain tissue of PML patients.
Infection with these viruses is common since 70 to 80 percent
of human sera tested was found to contain antibody.
Adenovirus, of which there are 34 different human
serotypes, often can be isolated from healthy human tissue,
such as the adenoidal or tonsillar tissue of most chil-
dren.-u- Respiratory disease, pharyngitis, and external
disease of the eye are caused by adenovirus infection,
although most infections are subclinical. There may be
persistent intermittent excretion of virus following clinical or
subclinical infection. The antibodies that arise to these
viruses persist for life.
All five types of human herpesviruses were put on the list
because latency is a characteristic of all herpesvirus
infections.-’ The oral strain of herpes simplex type 1 causes
gingivostomatitis as a primary infection in young children,
although many infections are subclinical. Keratitis and
sometimes encephalitis can follow type 1 infection. The
genital strain of herpes simplex type 2 produces lesions in
the genital organs and is spread by sexual contact. Babies
infected at birth acquire neonatal herpes with a lethality of
71 percent. By adulthood, 70 to 90 percent of the population
TABLE
Candidates for Human
DNA
Hepatitis B
BK and JC
Adeno
Human herpesviruses
Herpes simplex type 1
Herpes simplex type 2
Varicella-zoster
Cytomegalovirus
Epstein-Barr
Indigenous Viruses
RNA
Entero
Polio
Coxsackie A
Coxsackie B
Echo
Measles
Retro
Human type C leukemia
Foamy
have antibodies to herpes simplex. The virus persists in th
human body latent state in vertebral and sacral ganglior
Spontaneous recurrences of lesions are prompted by stres
on the body.24
Varicella-zoster virus causes chickenpox, a commoi ;
disease of skin and mucous membranes of children. Eight
percent of the population have antibody to V-Z.25 The virul
remains latent in the body in the nuclei of dorsal nervi1
ganglion similar to the way HSV does. Reactivation of laten
infection by trauma over the age of 45 leads to inflammatory
reaction of posterior nerve roots and ganglion, wit!
dermatomal distribution of skin lesions known as shingle;
or zoster.
Cytomegalovirus has caused an inapparent infection in 8(
percent of the population by 35 years of age.26 Infectior
during embryonic development sometimes causes severe
congenital abnormalities. Virus most easily is isolated from
the urine, but where it is latent in the human body is nofii
known-. It may be in the leucocytes. It has been isolated from
adenoids and has been found in salivary glands of 10 to 33
percent of autopsies on children. Fifty to 80 percent of the
population have antibodies to CMV. Often, the virus is
reactivated during immunosuppression, as in kidney
transplant patients.
Epstein-Barr virus, the most recently discovered human
herpesvirus, causes primary infection which mainly is,
subclinical in children, but infection of young adults can lead
to mononucleosis.27 Ninety percent of adults have antibodies
to EB virus, and it remains latent in the body somewhere
in the leucocytes. Stress can cause reactivation.
First on the list of RNA viruses is the enterovirus group,
which consists of the polio (3 types), coxsackie A (23 types), j
coxsackie B (6 types), and echo (33 types) viruses. They were
placed on the list because they can cause infection of the
alimentary canal in the absence of disease.28 Most infections
are subclinical, but when disease is produced, it can include
poliomyelitis, acute respiratory infection, aseptic meningitis,
herpangina, pleurodynia, hand, foot, and mouth disease, and
pericarditis. A large percentage of the population has
antibodies to many of these strains. Following a disease-
producing infection, virus can remain in the alimentary canal
for long periods, two to four weeks.
Measles virus was included because it sometimes can'
remain after primary clinical infection and then lead to the I
chronic neurological disease subacute sclerosing pan-
encephalitis (SSPE). y Virus can be found in lymph nodes and
in the brain tissue. A large percent of the population has :
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
122
intibodies to measles. German measles, or rubella, a member
pf the Toga virus group was not placed on the list, although
n congenitally infected infants, the virus may persist for
several years.
Retroviruses had to be included because many of them are
rue endogenous viruses, having the viral genome integrated
nto the cellular genome as a provirus.'0 In this way,
mdogenous means that viral genetic information is a
:onstant part of the genetic constitution of an organism.
Many vertebrate animals including chickens, mice, cats, and
baboons possess endogenous virus sequences. Man also may
possess endogenous virus sequences," but most of the
endogenous viruses have a very low disease-producing
potential. The majority have not yet been demonstrated to
transform cells in vitro or to be oncogenic in vivo. Recently,
the first human type C retrovirus has been isolated from T
' lymphocytes of leukemia patients.'2 Another retrovirus that
previously had been found in human cell culture is foamy
virus. It has not been associated with disease so far.
Ji
CONCLUSION
Many types of human viruses can be found in different
parts of the human body in the apparent absence of disease.
The function, if there is any, has yet to be discovered. Most
virologists would not consider them to be a normal flora.
In fact, the retroviruses, which in some cases can become
intimately connected to the cellular genome, are more truly
indigenous or endogenous than are the bacteria. Therefore,
the answer to the intriguing question which was posed in the
! introduction is that there are human indigenous viruses, but
most people would not consider them to be a normal viral
flora as comparable to the normal bacterial flora.
REFERENCES
1. Isenberg HD, Painter BG: Indigenous and pathogenic micro-
organisms of humans, in Lennette EH, Spaulding EH, Truant SA
(eds): Manual of Clinical Microbiology. Washington, D.C., Ameri-
can Society of Microbiology, 1980, pp. 25-29.
2. Davis BD, Dulbecco R, Eisen H, Ginsberg H (eds):
Microbiology, 3rd Edition. Harperstown, MD, Harper and Row,
Inc., 1980, pp. 808-810.
3. Jawetz E, Melnick J, Adelberg EA: Review of Medical
Microbiology. Los Altos, CA, Lange Medical Publication, 1980, pp.
283-286.
4. Joklik W, Willett HP: Zinsser-Microbiology. New York, NY,
Appleton-Centrury-Crofts, 1976, pp. 404-411.
5. Oldstone MB: Immunopathology of persistent viral infections.
Hospital Practice 17:61-72, 1982.
6. Melnick JL: Latent viral infections in donor tissues and in
recipients of vaccines, in Cell Cultures for Virus Vaccine Production.
National Can. Inst. Monograph 29, 1968, pp. 337-353.
7. Rapp F, Jerkofsky MA: Persistent and latent infections, in
Kaplan AS (ed): The Herpes Viruses. New York, NY, Academic
Press, 1973, pp. 271-289.
8. Luginbuhl RE: Viral flora of chick and duck tissue sources,
in Cell Culture for Virus Vaccine Production. Nat. Can. Inst.
Monograph 29, 1968, pp. 109-118.
9. Kniazeff AJ: Viruses infecting cattle and their role as
endogenous contaminants of cell culture, in Cell Culture for Virus
Vaccine Production. Nat. Can. Inst. Monograph 29, 1968, pp.
123-132.
10. Gillespie JH: Viral flora of canine tissue, in Cell Culture for
Virus Vaccine Production. Nat. Can. Inst. Monograph 29, 1968, pp.
113-139.
11. Wilner BJ: Viral flora of rabbits, in Cel! Culture for Virus
Vaccine Production. Nat. Can. Inst. Monograph 29, 1968, pp.
141-148.
12. Hull RN: Viral flora of primate tissue, in Cell Culture for
Virus Vaccine Production. Nat. Can. Inst. Monograph 29, 1968, pp.
173-175.
13. Hsiung GD: Detection of latent virus in kidney tissue, in Cell
Culture for Virus Vaccine Production. Nat. Can. Inst. Monograph
29, 1968, pp. 351-357.
14. Hsiung GD: Endogenous viral contaminants in animal tissue,
in Diagnostic Virology-Illustrated by Light and Electron Microscopy.
New Haven, CT, Yale University Press, 1982, pp. 252-262.
15. Kaiter SS, Hebesky RL: Viral flora of tissue sources-simian
and human, in Cell Culture for Virus Vaccine Production. Nat. Can.
Inst. Monograph 29, 1968, pp. 149-160.
16. Gitnick G: Non-A, non-B hepatitis, in Perspective on Viral
Hepatitis. Abbott Diagnostic Monograph, Chicago, IL, Abbott
Laboratory, 1981.
17. Hoofnagle JH: Types A and B viral hepatitis, in Perspectives
on Viral Hepatitis. Abbott Diagnostic Monograph, Chicago, IL,
Abbott Laboratory, 1981.
18. Perillo RP: The hepatitis viruses: Differential diagnosis, in
Perspective on Viral Hepatitis, Abbott Diagnostic Monograph,
Chicago, IL, Abbott Laboratory, 1981.
19. Padgett BL, Walker DL: New human papovaviruses. Prog
Med Virol 22:1, 1976.
20. Gardner SD, Field AM, Coleman DV, Huline B: New human
papovavirus (B.K.) isolated from urine after renal transplantation.
Lancet 1:1253, 1971.
21. Rowe WP, Heubner RS, Gilmore LK, Parrot RH, Ward TC:
Isolation of a cytopathogenic agent from human adenoids
undergoing spontaneous degeneration in tissue culture. Proc Soc
Exp Bio! Med 84:570, 1953.
22. Ginsberg HS: Adenoviruses, in Davis BD, Dulbecco R, Eisen
H, Ginsberg H: (eds): Microbiology, 3rd Edition. Harperstown, MD,
Harper and Row, Inc., 1980, pp. 1048-1060.
23. Nahmias AJ, Roizman B: Infection with herpes simplex vi-
ruses 1 and 2. N Eng! J Med 286:667, 1973.
24. Rawls WE: Herpes simplex virus types I and 2 and herpes
virus simiae, in Lennette EH, Schmidt NJ (eds): Diagnostic
Procedures for Viral Rickettsial, and Chlamydial Infections. Wash-
ington, D.C., American Public Health Association, 1979.
25. Weller TH: Varicella and herpes zoster, in Lennette EH,
Schmidt NJ (eds): Diagnostic Procedures for Viral, Rickettsial, and
Chlamydial Infections. Washington, D.C., American Public Health
Association, 1979, pp. 375-398.
26. Weller TH: The cytomegaloviruses: Ubiquitous agents with
protein clinical manifestations (2 parts). N Engl J Med 285: 203,
1971.
27. Henle W, Henle G, Howritz CA: Infectious mononucleosis
and Epstein-Barr virus associated malignancies, in Lennette EH ,
Schmidt NJ (eds): Diagnostic Procedures for Viral Rickettsial and
Chlamydial Infections. Washington, D.C., American Public Health
Association, 1979, pp. 441-470.
28. Melnick JL, Wenner HD, Phillips CA: Enteroviruses, in
Lennette EH, Schmidt NJ (eds): Diagnostic Procedures for Viral,
Rickettsial, and Chlamydial Infections. Washington, D.C., American
Public Health Association, 1979, 471-534.
29. Black FL: Measles, in Evans AS (ed): Viral Infections of
Humans, Epidemiology and Control. New York, NY, Plenum
Medical Books, 1976, p. 297.
30. Dulbecco R: Oncogenic viruses, in David BD, Dulbecco R,
Eisen H, Ginsberg H: Microbiology, 3rd Edition. Harperstown, MD.
Harper and Row, 1980, pp. 1231-1261.
31. Bonner TS, Connell CO, Cohen M: Cloned endogenous
retroviral sequences from human DNA. Pro Natl Acad Sci 79:
4709-4713, 1982.
32. Popvic M, Sarin PS, Robert-Gurroff M, Kaiyanaraman US,
Mann D, Minowoda J, Gallo RC: Isolation and transmission
human retrovirus (human T-cell leukemia virus). Science 219:
856-859, 1983.
VOL. 81— NUMBER 2— FEBRUARY 1984
123
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Vlay a Blood Bank Refuse Donations
ro Prevent the Spread of AIDS?
'EON G. SMITH, M.D., RICHARD BRENNAN, LL.D.,
IRIAN McDONOUGH, J.D., Newark*
— ;
The cause of acquired immunodeficiency syndrome (AIDS) is
rnknown. One hypothetical pathogenetic mechanism is transfusion of
olood donated by a victim of AIDS in a latent period. It is not possible
now to screen AIDS-infected blood by testing samples on an
individual basis, but screening donors from the dominant segments
of the population which are exclusive carriers of AIDS (homosexuals,
Haitians, and illicit drug users) is possible. The authors believe blood
donation facilities have a right and duty to ask suitable questions to
screen such donors. The legal questions of the individual’s right to
privacy, equal protection under the law, and the public health
are discussed.
This article will explore the legal and
constitutional implications of at-
tempting to contain the spread of
acquired immunodeficiency syndrome (AIDS) by refusing
blood donations from certain groups of donors based on
their ancestry, drug habits, and sexual orientation.
CASE REPORT
A 65-year-old heterosexual male, who was not a Haitian
nor a drug user, had coronary bypass surgery 18 months
prior to his admission. His chief complaints were cough,
fever, and chills for a week. The patient received ampicillin
at home for one week before admission. His physical examin-
ation was negative except for a macular papular drug erup-
tion due to ampicillin. Chest x-ray and arterial blood gas
levels were normal. Subsequently, he developed a positive
diffuse gallium scan of the lung and later a diffuse infiltrate
of the entire lung. Lung biopsy revealed Pneumocystis carmii.
The patient died despite proper sulfamethoxazol-
trimethoprim therapy.
The patient never had used any illicit drugs. He was not
exposed to anyone with AIDS. The donors of the blood he
‘received were reexamined and all were well. One donor
been a heroin user, but never volunteered this information.
He was not questioned about drug use, homosexuality, or
Haitian background for privacy reasons.
LEGAL RAMIFICATIONS
What are the legal ramifications of a case such as this?
One may start by asking what civil liability a blood bank
or a hospital-run blood donation facility might have violated
in a lawsuit brought by the patient's estate or survivors. It
is settled law in New Jersey that a blood bank cannot be
liable for unsafe blood under a theory of strict liability, that
is, absolute liability simply by virtue of its blood being unsafe
and having caused this man’s death. The facility can only
be held liable if its failure to detect the unsafe qualities in
the blood was due to a want of reasonable care on its part
and thereby negligent.1 The blood donation facility may
argue that it cannot be found negligent because the state of
the art, to our knowledge, does not allow blood samples to
*Dr. Smith is Director, Department of Medicine, Saint Michael's
Medical Center, Newark. Mr. Brennan and Mr. McDonough are
affiliated with Shanley & Fisher, Newark. Correspondence may be
addressed to Dr. Smith, Department of Medicine, Saint Michael’s
Medical Center, 268 High Street, Newark, NJ 07102.
VOL. 81— NUMBER 2— FEBRUARY 1984
125
be tested individually to detect the presence of AIDS. Were
this case that simple, the blood bank probably could not be
accused of negligence just as blood banks could not be found
negligent in the days when it was impossible to detect serum
hepatitis in the blood.
However, it is not that simple. While it may not be possible
to screen AIDS-infected blood by testing samples on an
individual basis, it nevertheless is possible to screen AIDS-
infected blood by screening donors from those segments of
the population which are the dominant, if not exclusive,
carriers of AIDS: homosexuals, Haitians, and drug users.
Given the uncanny tendency of AIDS to confine itself to
these segments of the population, an argument could be
fashioned that the blood bank’s failure to inquire into these
traits was a lack of reasonable care and, therefore, negligent.
This forces the blood bank into a painful position. If it
does not ask questions about homosexuality, Haitian origin,
or drug use, it runs a serious risk of civil liability for negli-
gently accepting and supplying unsafe blood. If it does ask
these questions, it will be prying into the private affairs of
its donors. In the case of homosexuals and Haitians, it also
would face the unpleasant task of rejecting applicants based
solely on sexual orientation or national origin. Under-
standably, blood bank personnel fear that they would be
acting illegally and intruding on the rights of these groups
to privacy and to equal protection of the laws.
Any fear by the blood banks of invading the constitutional
rights of its donors would not be well founded as a matter
of constitutional law. It is true that the past 20 years have
witnessed an unprecedented expansion of the individual’s
right to privacy and to equal protection of the laws. How-
ever, even the most valued rights to privacy and equal protec-
tion must yield to the overpowering public interest in free-
dom from disease and epidemic. Just as one's right to free
speech does not entitle him or her to yell fire in a public
theatre,2’6 one’s right to be left alone does not entitle him
or her to infect the neighbors and community with deadly
and infectious diseases. If there are ways of preventing this
epidemic without invading the privacy and equal protection
rights of the infecting individual, these means should be used.
However, if the disease cannot be controlled any other way
than by infringing on these freedoms, then it is submitted
that they may be infringed upon.
This principle was set down by Justice Harlan of the
United States Supreme Court in Jacobson v Massachu-
setts,1 a turn-of-the-century case which pitted the rights of
a man who did not want to be vaccinated against the need
of his community to protect itself from smallpox. After
noting that every state and community has the right to take
such measures as are necessary to protect the general health
and common welfare of its citizens, the court turned to
Jacobson’s argument that this interest was not so compelling
as to justify invading his bodily integrity through vaccination
or invading his liberty through fine or imprisonment for
failure to be vaccinated:
The defendant insists that his liberty is invaded when
the State subjects him to fine or imprisonment for
neglecting or refusing to submit to vaccination; that
a compulsory vaccination law is unreasonable, arbi-
trary and oppressive, and, therefore, hostile to the
inherent right of every freeman to care for his own
body and health in such a way as to him seems best;
and that the execution of such a law against one who
objects to vaccination, no matter for what reason,
is nothing short of an assault upon his person. But
the liberty secured by the Constitution of the United
States to every person within its jurisdiction does not
import an absolute right in each person to be, at all
times and in all circumstances, wholly freed from
restraint. There are manifold restraints to which
every person is necessarily subject for the common
good. On any other basis organized society could not
exist with safety to its members. Society based on the
rule that each one is a law unto himself would soon
be confronted with disorder and anarchy. Real liber-
ty for all could not exist under the operation of a
principle which recognizes the right of each individ-
ual person to use his own, whether in respect of his
person or his property, regardless of the injury that
may be done to others. This court has more than
once recognized it as a fundamental principle that
persons and property are subjected to all kinds of
restraints and burdens, in order to secure the general
comfort, health, and prosperity of the State; of the
perfect right of the legislature to do which no ques-
tion ever was, or upon acknowledged general prin-
ciples ever can be made, so far as natural persons
are concerned. ... In Crowley v Christensen, 137 U.S.
86, 89, we said: The possession and enjoyment of all
rights are subject to such reasonable conditions as
may be deemed by the governing authority of the
country essential to the safety, health, peace, good
order, and morals of the community. Even liberty
itself, the greatest of all rights, is not unrestricted
license to act according to one’s own will. It is only
freedom from restraint under conditions essential to
the equal enjoyment of the same right by others. It
is then liberty regulated by law.4
Nor did Justice Harlan even consider the potential merits
of Jacobson’s argument that the Massachusetts legislature
was wrong in its assumption that vaccination would prevent
or lessen the incidence of smallpox. As long as the state had
not acted arbitrarily and unreasonably in enabling com-
munities to require vaccination of their members as a safe-
guard against smallpox, the court declined to second guess
the legislature by evaluating the medical evidence anew and
deciding whether the legislature was correct. It was enough
that it had not been arbitrary or unreasonable and that there
was a real and substantial relation between the means used,
in that case vaccination, and the end sought, that of safe-
guarding the general health.5
So strong was the compelling public interest in the general
health that the court refused to exempt Jacobson from the
vaccination requirement by virtue of his subjective fear that
vaccination would endanger his health, a fear that was based
on his son s and his own severe childhood reactions to a
vaccination. In rejecting even this deeply felt argument, the
court answered resoundingly that “[W]e are not prepared to
hold that a minority, residing or remaining in any city or
town where smallpox is prevalent, and enjoying the general
protection afforded by an organized local government, may
thus defy the will of its constitutional authorities, acting in
good faith for all, under the legislative sanction of this state.
If such be the privilege of a minority, then a like privilege
would belong to each individual of the community, and the
spectacle would be presented of the welfare and safety of an
entire population being subordinated to the notions of a
single individual who chooses to remain a part of that popu-
lation.”6
The lesson of Jacobson v Massachusetts is clear: the health
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
126
ind safety of the entire community are paramount to the
irivacy and even the bodily integrity of one individual who
nay infect that community. Like draft registration and taxes,
his limitation on one's freedom is an inevitable price of
■njoying society's other protections.
Indeed, prospective blood donors who either are homosex-
jal or Haitian would pay a lesser price than did the individ-
j ,ial in Jacobson. In that case, a citizen was forced either to
iave a smallpox vaccine injected into his body or face fine,
mprisonment, or both. In this case the only cost would be
he invasion of privacy all donors would suffer from being
isked about their sexual orientation and, if they were black,
j ibout their national origin. The embarrassment and rejection
i homosexual or Haitian would feel by being singled out and
Iturned away from a blood donation facility are real. The
: need to protect the lives and health of potential donors
nevertheless should take precedence judging by the past
teachings of the Supreme Court.
We see no indication that the principles set forth in
Jacobson have diminished over time. While cases involving
contagious and infectious disease thankfully have dwindled
due to medical science, courts still reaffirm these principles
tat every opportunity. Local laws requiring that school chil-
dren be vaccinated as a condition of their enrollment have
been uniformly upheld even over objections that they viol-
rated religious liberty.7'" So strong is this commitment to the
preservation of life and health that courts and the state have
not hesitated to intervene in family relationships when
necessary to save the life of a spouse or a child over religious
objections, even when no threat of contagion to others is
involved. i: While this power normally is reserved to the
individual states, it may be exercised when necessary by the
federal government as demonstrated by the late 1970s swine
flu program.
Should this notion of paramount government power to
protect the general health have too absolutist a ring to it,
we hasten to point out that this right is not unfettered. In
closing his decision in Jacobson, Justice Harlan assured that
the court could interdict the law or regulation where its
enforcement would be “so arbitrary and oppressive in par-
ticular cases as to justify the interference of courts to prevent
wrong or oppression.” Had the petitioner been able to show
with “reasonable certainty,” rather than generalized fear,
that vaccination would endanger his health or well-being
then the court suggested the result would have been dif-
ferent.13 Likewise, were it possible to screen out AIDS-con-
taminated blood without invading the privacy of donors or
subjecting them to unequal treatment, then a court might
find that the donation facility should pursue that less in-
trusive course. However, we are aware of no effective and
acceptable method by which blood can be tested to detect
the presence of AIDS. Until medical science reaches that
stage, there is simply no other way to protect the lives of
prospective donors other than by making some necessary
inroads into the rights of Haitians and homosexuals.
One might rejoin that the right of privacy and of equal
protection have come a long way since Jacobson and today
Justice Harlan so unequivocally would not have
subordinated the right of the individual to the right of the
community to defend itself against disease. While eight dec-
ades of constitutional law might have altered Justice
Harlan’s analysis, we doubt that it would hav.e changed the
result.
The constitutional right of privacy undoubtedly has come
a long way since 1904. Today we recognize a constitutional
right of privacy in matters of contraception,14 procreation,15
sterilization,16 and even death17 — rights that were unheard of
in 1904. It is unclear, however, whether one’s sexual orien-
tation falls within this constitutionally recognized zone of
privacy. While compelling arguments can be made that this
intensely personal matter should be constitutionally
protected against outside interference, it is an open question
whether the federal courts would be ready to take this step
given their acquiescence in statutes outlawing private con-
sensual homosexual acts,18'19 requiring the separation of
homosexuals from the armed forces,20'21 and otherwise
diminishing the protections available to homosexuals.21'24
However, given the liberal tradition of New Jersey courts
in carving out new human rights under the aegis of the
common law and the New Jersey state constitution, we see
a viable possibility that they would recognize such a
right.25'27
“Even the most valued rights to
privacy and equal protection must
yield to the overpowering public
interest in freedom from disease
and epidemic.”
Were the right of privacy to sexual orientation to be grant-
ed, however, to what extent would that right be invaded by
asking someone to state sexual orientation as a precondition
to giving blood? The due process clause protects one against
being deprived of his right to privacy, but this burden on
privacy does not appear to deprive the donor of the right
to live his or her own lifestyle or place an intolerable burden
on that lifestyle. Moreover, even the right to privacy may
at some point have to give way to other compelling state
interests. For example, we recognize a constitutional right
to privacy in deciding whether or not to have an abortion,
but require that interest to yield to the compelling state
interest in protecting potential life during the final trimester
of pregnancy.28
Another constitutional concern is whether turning
homosexuals and Haitians away from a blood donation fa-
cility would violate their constitutional rights to equal
protection of the law.-’4 We do not believe it would. Com-
munities and legislatures inevitably must draw distinctions
between different groups of people, bestowing or withhold-
ing certain benefits on the basis of age, geography, financial
status, and sex. Such practices comply with the equal protec-
tion clause as long as they bear a real and substantial relation
to a legitimate state objective,30 a test which most laws would
be hard pressed not to meet. In this case it hardly can be
disputed that refusing blood from homosexuals and Haitians
bears a real and substantial relation to a legitimate communi-
ty objective, that of protecting the public from contagious
disease.
However, any law which singled out Haitians or homosex-
uals for adverse treatment might be examined with a more
exacting eye. In recent years courts have held that any law
which discriminates on the basis of a suspect classification
will be subjected to strict scrutiny and upheld only if it is.
necessary to achieve a compelling state objective and if there
are no less intrusive means available for achieving that objec-
tive. Not many classifications qualify as “suspect,” and the
courts thus far have limited this category to classifications
VOL. 81— NUMBER 2— FEBRUARY 1984
127
based on race, nationality, alienage, or religion.31'34 Haitians
would qualify for this higher level of “strict scrutiny” in that
they are being singled out on the basis of nationality (it is
questionable whether discrimination against them would be
classified as being based on race or alienage, in that non-
Haitian blacks or aliens still would be permitted to donate
blood). No courts have found homosexuals to be a suspect
class and several have declined to do so.'5
Also, a law which does not discriminate on the basis of
race, nationality, or alienage nevertheless may be subject to
strict scrutiny if it imposes a direct and substantial burden
on a fundamental right, such as the right to privacy.36,37 Were
sexual orientation included within the constitutional right to
privacy, which we have concluded is open to debate, it is
an interesting question whether refusal to accept blood dona-
tions by homosexuals would be a direct and substantial
burden on their right to their own lifestyle. While the
financial inconvenience of being unable to donate to a com-
mercial facility may be minimal, one nevertheless may feel
degraded and stigmatized if a blood bank refused to take
one’s blood for transmission to the rest of the populace. If
this seems frivolous, imagine how Catholics or Jews might
feel if a blood bank capriciously refused to accept their blood
as unfit for injection into the populace at large. The dif-
ference between this case and that hypothetical, of course,
is that a blood bank fearful of spreading AIDS to its donors
is acting not out of caprice but out of a duty to protect the
lives of its donees.
Therefore, even if homosexuals as well as Haitians were
found to be a suspect class, or if refusal to accept homosex-
uals’ blood did directly burden their right to privacy, we
believe that they still could be rejected by blood banks be-
cause their exclusion is absolutely necessary to achieve what
may be the most compelling of all compelling state interests,
the protection of the public health by limiting the spread of
AIDS.
In analyzing the constitutional implications of this dilem-
ma, we have to some degree put the cart before the horse.
We have assumed throughout this discussion that the blood
donation facility would be capable of violating the constitu-
tion. This brings to the fore the constitutional concept
known as “state action.”
It is rudimentary constitutional law that only the govern-
ment can violate the constitutional guarantees to equal
protection or privacy.37 Individuals need not comply with
these guarantees; freedom of association encompasses the
right to choose one’s friends on the basis of race or sexual
orientation or whatever other yardstick one chooses to use.
Therefore, a state or federally run hospital or blood dona-
tion facility clearly would be governed by these constitu-
tional commands; a purely private commercial facility prob-
ably would not be, although it could be held to be affected
with a state interest.
What about a hospital or facility that, while privately
owned and run, receives significant government assistance
in the form of aid, tax exemptions, and other statutory
benefits? The line between public and private action increas-
ingly has become blurred in recent years as more and more
ostensibly private agencies assume quasi-public charac-
teristics or perform services for the government that it would
otherwise have to perform for itself. Therefore, courts have
adopted a doctrine known as “state action” to determine
whether ostensibly private conduct has so implicated the
agencies of the state that it is tantamount to unconstitutional
state conduct. The Supreme Court has employed this
analysis to bar courts from enforcing racially restrictive covt
nants in real estate agreements'8 and to bar a municipt
parking facility from leasing space to a restauranteur wh
refused to serve blacks.39,40
The courts have retrenched somewhat in the last 15 yean I
however, and have refused to classify government assistant
to a private party as “state action” unless that assistance
actually fosters or encourages the unconstitutional conduc
This narrowing of “state action” was signalled by the Si
preme Court’s holding that furnishing a state liquor licens :
to a discriminatory private club was not state action. Because
the state was a neutral which issued liquor licenses to dis
criminatory and nondiscriminatory clubs alike, the coui
concluded that issuance of a state liquor license did no ,
encourage or foster the discrimination and refused to fin<
“state action.”41 Courts have since refused to find such actio:
unless the nexus between the government and the privat
|
facility is so close that the actions of the latter may fairl
be said to be the actions of the former. Such a nexus onl
will be found where the government encourages or partici
pates in the action, mere acquiescence is not enough.42,4'
Therefore, the Supreme Court refused to apply the “stall .
action” concept to a private nursing home despite the state’ ;
pervasive involvement in regulating and subsidizing th< ’
home as well as in adjusting the level of its Medicaid benefit:
in accordance with private decisions made by the employees:
of those facilities.44 Similarly, numerous lower courts havt
refused to apply the state action concept to hospitals,45,46 anc
private outpatient facilities such as a kidney dialysis center.4
We, therefore, think it unlikely that the actions of a blooc
bank or a hospital would even amount to “state action’
much less actually violate the Constitution.48,49
CONCLUSION
It is entirely possible that a duty could be imposed or,:
blood donation facilities to prevent the spread of AIDS by1
asking questions to screen donors who are homosexual oi
Haitian, or who have a history of illicit drug use. Any feai
of invading the rights of these donors to privacy or to equal
protection does not appear to have a sound foundation in
law. As weighty as these considerations might be, they
almost certainly would be found to yield to the over-
whelming community interest in preventing disease and con-
tagion. Given the current state of the science, there does not
appear to be any less restrictive a way of achieving this end.
Moreover, it is questionable whether a private facility would;
be held liable for violating these rights even if it wished to.
We note that no court has yet passed on this question.
Any actual decisions would be made on a case-by-case ap-(
proach on the basis of a full factual record. For that reason,
this article is not intended to be definitive legal advice on
the subject nor should it be so taken. Rather, this has simply
been an opportunity for us to explore a current and con-
troversial medical issue in the context of the common law
and the Constitution.
REFERENCES
1. Brody v Overlook Hospital, 127 N.J. Super. 331 (App. Div.
1974), aff'd 66 N.J. 448 (1975).
2. Schenck v United States, 249 U.S. 47 (1919) (Oliver Wendell
Holmes, J.).
3. 197 U.S. at 11 (1905).
4. 197 U.S. at 26.
5. 197 U.S. at 30-37.
6. 197 U.S. at 37-38.
7. Mountain Lakes Board of Education v Maas, 56 N.J. Super. 245,
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
128
,4-67 (App. Div. 1959) aff'd. 31 N.J. 537 (1960).
8. Sadlock v Board of Education of Carlstadt, 1 37 N.J. L. 85, 87-91
up. Ct. 1948).
9. Davis v Stale, MD, 451 A. 2d 107, 111-112 (Ct. App. 1982).
10. McCartney v Austin, 57 Misc. 2d 525, 293 N.Y.S. 2d 188 (Sup.
It. 1968).
11. Wright v Dewitt School Dist. I, 238 Ark. 906, 385 S.W. 2d
14 (Sup. Ct. 1965).
12. Application of the President & Directors of Georgetown Col-
?e, 331 F. 2d 1000 (D.C. Cir.), cert, denied. 377 U.S. 978 (1964).
13. 197 U.S. at 38-39.
14. Eisendstadt v Baird. 405 U.S. 438 (1972); Griswold v Connecti-
on. 381 U.S. 479 (1965).
15. Roe v Wade. 410 U.S. 113 (1973).
16. In re Grady, 85 N.J. 235 (1981).
17. In re Quinlan, 70 N.J. 10 (1976).
18. American Civil Liberties Union Handbook: The Rights of Gay
eople, 1983 Appendix A at 131-166.
19. New York v Onofre, 424 N.Y.S. 2d 566 (N.Y. Sup. Ct. 1980).
20. Belter v. Middendorf 632 F.2d 788 (9th Cir. 1980), cert, denied
30 U.S. 965 (1981).
21. Ben Shalom v Sec’y of the Army, 489 F. Supp. 964 (E.D. Wis.
980).
22. McConnell v Anderson, 451 F. 2d 193 (8th Cir. 1971), cert.
\nied 405 U.S. 1046 (1971).
23. Gaylord v Tacoma School Dist. No. 10, 88 Wash. 2d 286, 559
.2d 1340 (1977), cert, denied, 434 U.S. 879 (1977).
24. Nemetz, 485 F. Supp. 470 (E.D. Va. 1980).
25. Fricke v Lynch, 491 F. Supp. 381 (D.R.I. 1980), vacated and
■manded, 627 F.2d 1088 (1st Cir. 1981).
26. State v Saunders, 75, N.J. 200 (1977).
27. Southern Burlington County N.A.A.C.P. v Mount Laurel, N.J.
983).
28. In re Grady, 85 N.J. 235 (1981) (state constitutional right of
(rivacy extends to the right to be sterilized); State v Schmid, 84 N.J.
j35 (1980) appeal dismissed, 455 U.S. 100 (1982) (state constitu-
onal right of free speech guarantees reasonable access to private
university campus); In re Quinlan, 70 N.J. 10 (1976), cert, denied,
429 U.S. 922 (1976) (state constitutional right of privacy extends to
the right of choice to terminate life support systems); State v John-
son, 68 N.J. 349 (1975) (state constitution may guarantee greater
freedom from unreasonable searches and seizures than does the
federal constitution).
29. Roe v Wade, supra, 410 U.S. at 163-64.
30. U.S. Const., Amend. 14 (applying to the states), Amend. 5
(applying to the federal government).
31. San Antonio School Dist. v Rodriguez, 41 1 U.S. 1, 40 (1973).
32. Regents of the University of California v Bakke, 438 U.S. 265,
306 (1978); San Antonio School Dist. v Rodriguez, supra, 411 U.S.
at 16-17.
33. Graham v Richardson, 403 U.S. 365, 375-76 (1971).
34. Craig v Boren, 429 U.S. 190, 197-98 (1976), and might employ
such an analysis if squarely confronted with a compelling case of
discrimination based on sexual orientation.
35. Belter v Middendorf, supra note 18 at 808-09.
36. Beller v Middendorf, supra, 632 F.2d at 807-110; DeSantis v
Pacific Tel. & Tel. Co., 608 F. 2d 327 (9th Cir. 1979).
37. San Antonio School Dist. v Rodriguez, supra, 411 U.S. at
16-17; Massachusetts Bd. of the Retirement v. Murgia, 427 U.S 307,
312-13 (1976).
38. Graham v Richardson, supra, 403 U.S. at 375-76.
39. Shelley v Kraemer, 334 U.S. 1 (1948).
40. Burton v Wilmington Parking Authority, 365 U.S. 715 (1961).
41. Marsh v. Alabama, 326 U.S. 501 (1946).
42. Moose Lodge No. 107 v Irvis, 407 U.S. 163 (1972).
43. Blum v Yaretsky, U.S. 73 L.Ed 2d 534 (1982).
44. Jackson v Metropolitan Edison Co., 419 U.S. 345 (1974).
45. Blum v Yaretsky, supra.
46. See, e.g., Modaber v Culpeper Memorial Hospital, Inc., 674
F. 2d 1023 1026 n.10 (4th Cir. 1982).
47. Newson v Vanderbilt University, 653 F. 2d 110 (6th Cir. 1981).
48. Greenspan v National Medical Care, Inc., 485 F. Supp. 311
(E.D. Va. 1980).
49. State v Schmid, supra note 20.
/OL. 81— NUMBER 2
FEBRUARY 1984
129
An added complication...
in the treatment of bacterial bronchitis*
hour The effect on nursing infants Is not known Caution should be
exercised when Ceclor* (cefaclor, Lilly) is administered to a nursing
woman
Usage m Children — Salety and effectiveness of this product for use
in infants less than one month of age have not been established
Adverse Reactions: Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2.5 percent of patients
and include diarrhea (1 in 70).
Symptoms of pseudomembranous colitis may appear either during
or after antibiotic treatment Nausea and vomiting have been reported
rarely
Hypersensitivity reactions have been reported in about 1 5 percent
of patients and include morbilliform eruptions (1 in 100) Pruritus,
urticaria, and positive Coombs' tests each occur in less than 1 in 200
patients Cases of serum-sickness-like reactions (erythema
multiforme or the above skin manifestations accompanied by
arthritis/arthralgia and, frequently, fever) have been reported These
reactions are apparently due to hypersensitivity and have usually
occurred during or following a second course of therapy with Ceclor
Such reactions have been reported more frequently in children than in
adults Signs and symptoms usually occur a fewdays after initiation
of therapy and subside within a few days after cessation of therapy
No serious sequelae have been reported Antihistamines and
corticosteroids appear to enhance resolution of the syndrome
Cases of anaphylaxis have been reported, half of which have
occurred in patients with a history of penicillin allergy.
Other effects considered related to therapy included eosinophilia
(1 in 50 patients) and genital pruritus or vaginitis (less than 1 in 100
patients)
Causal Relationship Uncertain— Transitory abnormalities in clinical
laboratory test results have been reported Although they were of
uncertain etiology, they are listed below to serve as alerting
information for the physician
Hepatic — Slight elevations of SCOT, SGPT, or alkaline phosphatase
values (1 in 40).
Hematopoietic— Transient fluctuations in leukocyte count,
predominantly lymphocytosis occurring in infants and young children
(1 in 40).
Renal— Slight elevations in BUN or serum creatinine (less than 1 in
500) or abnormal urinalysis (less than 1 in 200).
(061782R)
* Many authorities attribute acute infectious exacerbation of chronic
bronchitis to either S. pneumoniae or H influenzae *
Note Ceclor is contraindicated in patients with known allergy to the
cephalosporins and should be given cautiously to penicillin-allergic
patients
Penicillin is the usual drug of choice in the treatment and
prevention of streptococcal infections, including the prophylaxis of
rheumatic fever See prescribing information
References
1 Antimicrob. Agents Chemother ,8 91. 1975.
2 Antimicrob Agents Chemother . 11 470. 1977
3 Antimicrob. Agents Chemother , 13 584, 1978
4. Antimicrob Agents Chemother , 12 490, 1977
5 Current Chemotherapy (edited by W Siegenthaler and R. Luthy),
!|lg880 Washington, D C American Society for Microbiology,
6 Antimicrob Agents Chemother , 13 861, 1978
7 Data on file, Eli Lilly and Company
8 Principles and Practice of Infectious Diseases (edited by G.L
Mandell, R.G Douglas. Jr., and J E Bennett), p 487 New York:
John Wiley & Sons. 1979
© 1982. ELI LILLY AND COMPANY
Additional information available to
the profession on request from
Eli Lilly and Company.
Indianapolis. Indiana 46285
Eli Lilly Industries, Inc.
Carolina. Puerto Rico 00630
Indications and Usage: Ceclor* (cefaclor. Lilly) is indicated in the
treatment of the following infections when caused by susceptible
strains of the designated microorganisms
Lower respiratory infections, including pneumonia caused by
Streptococcus pneumoniae (Diplococcus pneumoniae), Haemophilus
mtluemae, andS pyogenes (group A beta-hemolytic streptococci)
Appropriate culture and susceptibility studies should be performed
to determine susceptibility of the causative organism to Ceclor
Contraindication: Ceclor is contraindicated in patients with known
allergy to the cephalosporin group of antibiotics
Warnings: IN PENICILLIN-SENSITIVE PATIENTS, CEPHALOSPORIN
ANTIBIOTICS SHOULD BE ADMINISTERED CAUTIOUSLY THERE IS
CLINICAL AND LABORATORY EVIDENCE OF PARTIAL CROSS-
ALLERGENICITY OF THE PENICILLINS AND THE CEPHALOSPORINS
AND THERE ARE INSTANCES IN WHICH PATIENTS HAVE HAD
REACTIONS. INCLUDING ANAPHYLAXIS, TO BOTH DRUG
CLASSES
Antibiotics, including Ceclor, should be administered cautiously to
any patient who has demonstrated some form of allergy, particularly
to drugs
Pseudomembranous colitis has been reported with virtually all
broad-spectrum antibiotics (including macrolides, semisynthetic
penicillins, and cephalosporins); therefore, it is important to consider
its diagnosis in patients who develop diarrhea in association with the
use of antibiotics Such colitis may range in severity from mild to
life-threatening
Treatment with broad-spectrum antibiotics alters the normal flora
of the colon and may permit overgrowth of Clostridia. Studies
indicate that a toxin produced by Clostridium difficile is one primary
cause of antibiotic-associated colitis.
Mild cases of pseudomembranous colitis usually respond to drug
discontinuance alone In moderate to severe cases, management
should include sigmoidoscopy, appropriate bacteriologic studies, and
fluid, electrolyte, and protein supplementation When the colitis does
not improve after the drug has been discontinued, or when it is
severe, oral vancomycin is the drug of choice for antibiotic-
associated pseudomembranous colitis produced by C difficile Other
causes of colitis should be ruled out
Precautions: General Precautions— If an allergic reaction to Ceclor
occurs, the drug should be discontinued, and. if necessary, the
patient should be treated with appropriate agents, e g . pressor
amines, antihistamines, or corticosteroids
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms Careful observation of the patient is
essential If superinfection occurs during therapy, appropriate
measures should be taken
Positive direct Coombs tests have been reported during treatment
with the cephalosporin antibiotics. In hematologic studies or in
transfusion cross-matching procedures when antiglobulm tests are
performed on the minor side or in Coombs' testing of newborns
whose mothers have received cephalosporin antibiotics before
parturition, it should be recognized that a positive Coombs' test may
be due to the drug
Ceclor should be administered with caution in the presence of
markedly impaired renal function. Under such conditions careful
clinical observation and laboratory studies should be made because
safe dosage may be lower than that usually recommended
As a result of administration of Ceclor, a false-positive reaction for
glucose in the urine may occur This has been observed with
Benedict's and Fehlmg's solutions and also with Clinitest* tablets but
not with Tes-Tape* (Glucose Enzymatic Test Strip, USP. Lilly)
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history of gastrointestinal disease particularly
colitis
Usage in Pregnancy— Pregnancy Category B— Reproduction
studies have been performed in mice and rats at doses up to 12 times
the human dose and in ferrets given three times the maximum human
dose and have revealed no evidence of impaired fertility or harm to
the fetus due to Ceclor There are, however, no adequate and
well-controlled studies in pregnant women Because animal
reproduction studies are not always predictive of human response
this drug should be used during pregnancy only if clearly needed
Nursing Mothers— Small amounts of Ceclor have been detected in
mother's milk following administration of single 500-mg doses
Average levels were 0 18. 0 20, 0.21. and 0.16 mcg/ml at two, three
four, and five hours respectively Trace amounts were detected at one
Some ampicillin-resisfant strains of
Haemophilus influenzae— a recognized
complication of bacterial bronchitis*-are
sensitive to treatment with Ceclor.18
In clinical trials, patients with bacterial bronchitis
due to susceptible strains of Streptococcus
pneumoniae, H. influenzae, S. pyogenes
(group A beta-hemolytic streptococci), or multiple
organisms achieved a satisfactory clinical
response with Ceclor.7
cefaclor
Putvules®, 250 and 500 mg
130
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
OASE REPORTS
— r"-mwmM— --Tnri:a.«/ro<^ |i -[ , ,, mmmi
Hydatid Disease of the liver
MICHAEL A. KESSLER, M.D., SIDNEY KETYER, M.D.,
JOHN V. CHOLANKERIL, M.D., JESUS CENIZAL, M.D., Elizabeth*
Chronic, recurrent upper abdominal pain in an individual from an
area of the world endemic for echinococcosis disease should lead one
to suspect hydatid disease of the liver. Two of three patients with
characteristic ultrasound and computed tomographic features of this
disease were proved to ha Echinococcus granulosus. The morpho-
logic findings may be specific, suggestive, or nonspecific but radio-
logic evaluation provides a strong diagnostic technique in such cases.
Hydatid disease involving the liver,
due to Echinococcus granulosus, has
become a relatively easy condition
to demonstrate over the past several years utilizing ul-
trasound and computed tomography. Although the ap-
pearance not always is specific, sometimes the radiologic
presentation permits a specific diagnosis to be made. Our
experience with three patients stimulated a review of the
literature.
CASE REPORT 1
A 46-year-old female, who came from Greece in the past
year, was admitted to St. Elizabeth Hospital on December
15, 1976, with right upper quadrant abdominal pain. She
gave a history of recurrent similar episodes over the previous
two years, beginning while in Greece. The pain was as-
sociated with nausea and vomiting. The patient also reported
recent fatty food intolerance.
Upon admission, physical examination revealed mild jaun-
dice that developed over the previous two weeks. There was
rebound tenderness in the right upper quadrant, but because
of guarding, the liver was difficult to palpate.
Pertinent laboratory data included hemoglobin 11 gm;
hematocrit 32; WBC 7,000. Total bilirubin was 6.4 mg/dl
with direct of 4 mg/dl.
Ultrasound examination revealed a multiloculated cystic
structure involving most of the liver (Figure 1). The common
bile duct was not identified.
Surgery was performed and tissue was removed for
pathological examination. Hydatid cystic disease secondary
to Echinococcus granulosus was found. The biliary tract was
described at surgery as completely obliterated by the
pathology.
CASE REPORT 2
A 56-year-old male, a relative of our first patient, also
originally came from Greece. He was admitted to St. Eliz-
abeth Hospital on May 1, 1978, with upper abdominal
discomfort and nausea and vomiting.
Pertinent physical findings consisted of epigastric ten-
derness, but no masses or organomegaly were noted. Ul-
trasound study of the abdomen showed a 9 cm cystic
structure occupying the lower portion of the liver (Figure 2).
There was a small daughter cyst noted within the larger cyst.
Upon exploratory laparotomy and examination of aspirated
fluid, echinococcal cyst (Echinococcus granulosus ) was con-
firmed.
CASE REPORT 3
A 65-year-old male, born and raised in southern Italy,
noted increasing abdominal girth over a three-year period.
He denied pain or any other symptoms. Ultrasound and CT
*From the Department of Radiology, St. Elizabeth Hospital. Cor-
respondence may be addressed to Dr. Kessler, St. Elizabeth Hospi-
tal, 225 Williamson Street, Elizabeth, NJ 07207.
VOL. 81— NUMBER 2— FEBRUARY 1984
131
examinations showed huge multiloculated cystic structures in
the liver (Figures 3 and 4). Based on this appearance,
echinococcal disease was suspected. However, the patient
refused any further studies or treatment, and the diagnosis
never was proved. This case is included because the ul-
trasound and CT features are identical to cases of echinococ-
cal liver involvement found in the radiological literature.4,8
DISCUSSION
In the United States, one is not likely to consider
echinococcosis disease despite a clinical presentation consis-
tent with it. However, particularly with world travel and
migration, the epidemiological patterns have shown change.4
Echinococcal disease often causes upper abdominal pain that
may be recurrent and chronic. Such a clinical presentation
often will prompt the physician to request an abdominal
ultrasound examination. One may consider the diagnosis
when simple or more complex cystic structures are found in
the liver. If the patient has spent time in one of the endemic
areas, the diagnosis can be considered with more confidence.
Our first two patients originally came from Greece and were
members of the same family. Our third patient came from
Italy which also is an endemic area for the disease.
Hydatid (a drop of water) disease may be caused by either
one of two species of tapeworm.10 Most commonly, the
organism is Echinococcus granulosus, which is endemic in
South America, the Near and Middle East, North Africa,
Australia, New Zealand, and southern Europe. The less
common organism, Echinococcus alveolaris most commonly
is seen in central Europe, Russia, Alaska, Japan, and the
United States.1'2'3,6
The life cycle of E. granulosus has been well de-
scribed.1,4,5,11 The primary host is the dog, which harbors the
adult form in the small bowel villi. Eggs in the dog’s feces are
ingested by the intermediate host, usually sheep and cattle,
but occasionally man. Areas of cattle and sheep raising
therefore are sites that will be endemic. The eggs hatch in
duodenum and liberate oncospheres; these migrate to the
liver via the portal circulation, where, for the most part, they
are filtered. A second filter is the pulmonary circulation.5
Beyond this, a small percentage gets to the brain, kidneys,
and bone.
RADIOLOGIC FINDINGS
In the liver, hydatid disease secondary to E. granulosus can
show several different echogenic patterns. Hadidi described a
classification of four different patterns: solitary cysts; large
cyst with one or more smaller daughter cysts within it;
multiloculated cyst; and multiple cysts.7 If internal echoes are
present in these cystic structures, such presentation could
signify suppuration, with secondary infection of the cysts.
Gharbi et al. described the findings of 121 patients in
Tunisia and presented a similar, although more complex
classification.6
The finding in our case 1 was a solitary cyst; the liver in
case 2 revealed a daughter cyst within a larger cyst; and case
3 showed a septated multiloculated cystic structure shown on
both ultrasound and computed tomography. The solitary
cyst is not ultrasonographically specific, since simple cysts,
abscess, hematoma, and metastasis can give this appearance.
The presence of a daughter cyst, however, is quite specific for
hydatid disease.7 The multiloculated cyst appearance also
can be the result of a tumor, such as a hepatic cystadenoma;
the multiple cysts would have a nonspecific appearance.
Posterior
Figure 1 — Transverse ultrasound image showing multiloculati
cystic structure involving most of the liver (A) and longitudir
scan 2 cm to the left of the midline (B) in patient 1.
Figure 2— Longitudinal ultrasound image 7 cm to the right of th
midline showing large cyst in lower part of right lobe of liver i
patient 2. Small daughter cyst is present. This appearance
virtually diagnostic for echinococcosis.
132
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’1
Anterior
l
igure 3 — Transverse ultrasonogram showing multiloculated
ystic structure in liver in patient 1 (A). Longitudinal sonogram
if same patient, slightly to the right of the midline (B).
The computed tomographic (CT) findings in E. granulosus
nvolvement of the liver also are described in the literature.4,9
The cystic structures are well defined and contain fluid-filled
Interiors with densities between 3 and 30 Hounsfield (HU)
units. The same types of patterns as seen on ultrasound are
bund.
f E. alveolaris, which is seen less often then E. granulosus, is
described by Scherer et al. as showing, on CT scan, a low
(density (14 to 38 HU) irregular mass lesion in the liver with
no visible surrounding membrane.9 It will resemble an
mvasive tumor and the correct diagnosis cannot be made
radiographically.
SUMMARY
Three patients have been described, the first two of whom
were documented by surgery and pathological examination
to have hydatid disease of the liver. The first patient’s
ultrasound examination was suggestive of echinococcosis
with multiloculated cystic structures. The second patient
showed a daughter cyst making the appearance virtually
specific. The third patient showed another striking multi-
septated cystic structure on ultrasound and CT examinations
that was identical to that in other cases of echinococcosis
presented in the literature.
Figure 4 — Computed tomography image 8 cm below the
xiphoid shows multiloculated cystic structure in liver in patient 3.
The fluid in the cyst was approximately water density and did not
enhance following contrast. The morphology is similar to that
demonstrated by ultrasound in Figure 3A, which was in a similar
orientation.
REFERENCES
1. Alltree M: Scanning in hydatid disease. Clin Radiol 30:691-697,
1979.
2. Babcock O, Kaufman L, Codnow I: Ultrasound diagnosis of
hydatid (echinococcosis) in two cases. Am J Roentgenol 131:895-897,
1978.
3. Biggi E, Derchi L, Cicio G R, Valente M: Sonographic findings
of hydatid cyst of the liver ruptured into the biliary ducts. J Clin
Ultrasound 7:381-382, 1979.
4. Choliz JD, Lecumbern Oloverri FJ, Franquet Casas T, Ostiz
Zubieta S: Computed tomography in hepatic echinococcosis. AJR
139:699-702, 1982.
5. Gonzalez LR, Marcos J, Illanas M, Hernandez-Mosa M, et al.:
Radiologic aspects of hepatic echinococcosis. Radiology 130:20-27,
1979.
6. Gharbi HA, Hassine W, Brauner, MW, Dupach K: Ul-
trasound examination of the hydatic liver. Radiology 139:459-463,
1981.
7. Hadidi A: Ultrasound findings in liver hydatid cysts. J Clin
Ultrasound 7:365-368, 1979.
8. Kirschner LP, Ferns RA, Mero JH, Moss ML: Hydatid disease
of the liver evaluated by computed tomography. J Comput Totnogr
2:229-236, 1978.
9. Scherer U, Weinziel M, Sturm R, Schildberg FW: Computed
tomography in hydatid disease of the liver: A report on 13 cases. J
Comput Assist Tomogr 2:612-617, 1978.
10. Steadman’s Medical Dictionary. Baltimore, MD, Williams &
Wilkins Co., 1966, p. 753.
11. Weirch WL: Hydatid disease of the liver. Am J Surg
138:805-808, 1979.
VOL. 81— NUMBER 2— FEBRUARY 1984
133
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER
"ine-Needle Aspiration in
VLetastatic Malignant Melanoma
ONALD ROTHMAN, M.D., YAYONE OLAIZOLA, M.D.,
)HN BAKER, C.T., Red Bank*
line patients in the past three years had percutaneous fine-needle
spiration of metastatic subcutaneous nodules and masses using a
uick stain of air-dried material. The results led to more prompt
urgical treatment and established proof of metastases, and made
he diagnosis in two cases with occult primaries.
Fine-needle aspiration (FINA) of
various lesions (breast, thyroid,
lung, pancreas, and brain) is gain-
ng wider popularity. We will discuss the usefulness of FINA
of nodules in melanoma patients since clinical information
about secondary lesions often determines the prognosis and
role of further surgery. Palpation alone notoriously is mac-
erate. Therefore, cytology of readily accessible masses
would appear a rapid, simple way to establish proof of
metastatic disease. Recent experience with a variety of cases
prompted this report (Table).
METHODS
A 1 ‘/2-inch, 22-gauge needle on a 20 cc plastic syringe in
a special syringe holder is thrust into the lesion, which is held
in place by the Fingers. The needle is moved up and down
in the mass numerous times with 10 cc of suction applied.
Cytological material is fractured off by the needle cutting
edge and aspirated into the needle (not the syringe); the
suction is released and allowed to equilibrate while the needle
still is in the tissue. After withdrawal, the needle is removed,
air introduced into the syringe, and the needle replaced. The
specimen from the needle is blown onto a slide, smeared,
and air-dried. Diff-quik stain is used. After drying and cov-
erslipping, cytological review is made. Characteristic malig-
nant melanocytes and some with pigment can be appreciated.
CASE REPORTS
A 50-year-old man developed a 2 cm right axillary recur-
rence proved by needle biopsy. One year earlier he had
bilateral axillary lymphadenectomy for chest wall melanoma
at Sloan-Kettering Memorial Hospital, New York. The pa-
tient promptly returned to his original surgeon for more
radical treatment.
A 57-year-old woman had a malignant mole excised 20
years earlier from the right forearm and skin grafting. She
presented with a 10 cm fixed axillary mass, proved to be
metastatic melanoma upon aspiration biopsy. The lesion was
unresectable.
A 55-year-old man proved to have recurrent metastatic
melanoma with a fine-needle aspiration biopsy of an ab-
dominal wall lesion (Figure 1). He did not respond to
dacarbazine (DTIC) or radiation.
A 55-year-old man with an infected superficial spreading
melanoma of the nipple was treated with wide excision after
being treated for dermatitis of the breast for two to three
months. A left axillary node aspiration indicated
lymphadenitis and subsequently this has subsided under ob-
servation.
♦From the Departments of Surgery and Pathology, Riverview Hos-
pital, Red Bank. Correspondence may be addressed to Dr.
Rothman, 565 Highway 35, Red Bank, NJ 07701.
VOL. 81— NUMBER 2— FEBRUARY 1984
135
Figure 1— Large irregular cells with dark irregular nuclei and
abundant cytoplasm (large arrow) are many times the size of
polymorphs (small arrow) (diff-quik stain at 400 power).
Figure 2— Lymph node metastasis.
Figure 3— Large melanoma cell with pigment (large arrow:
many times the size of RBC (small arrow) (diff-quik stain at 40
power).
A 75-year-old man presented with a small cutaneous lesio
of the back and a large axillary mass. Aspiration of the mas.
indicated metastatic neoplasm. Subsequently, an excision c
the primary melanoma of the back and lymphadenectom
were carried out.
A 44-year-old man presented with a melanoma of the bac
which was widely excised and skin grafted. Several month
later, a node in the axilla was aspirated and found to hav
metastatic melanoma; he underwent a node dissection (Fig
ure 2).
A 30-year-old man underwent wide excision of a mela
noma of the left shoulder. Three months later, a left axillar
node yielded positive cells and an axillary dissection wa:
carried out.
A 27-year-old woman presented with a subcutaneou;
nodule of the right neck. Fine-needle aspiration yieldec
heavily pigmented melanoma cells (Figure 3) with no pri
mary site. A radical neck dissection was promptly carriec
TABLE
Recent Experience
Age
Sex
Presentation
Aspirate
Treatment
Followup
50
M
Recurrent mass in axilla
Positive
Further surgery
Expired
57
F
Recurrence in axilla
Positive
None
Expired
55
M
Recurrence in abdominal wall
Positive
None
Expired
55
M
Superficial melanoma of
breast— with axillary node
Negative
None
Node receded
75
M
Skin lesion and axillary mass
Positive
Wide excision
lymphadenectomy
Expired
44
M
Axillary recurrence
Positive
Axillary node
dissection
Subsequent recurrences
30
M
Axillary recurrence
Positive
Axillary node
dissection
No evidence of disease
(6 months)
27
F
Neck nodules, unknown
primary
Positive
Neck dissection
No evidence of disease
(6 months)
57
M
Groin node, unknown
primary
Positive
Groin dissection
No evidence of disease
(1 year)
136
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
it at Sloan-Kettering Memorial Hospital.
I A 57-year-old man developed a mass in the groin. Fine-
Sfedle aspiration yielded melanoma cells in a lymph node;
}j> primary was found. He subsequently underwent radical
oin dissection at the University of Pennsylvania Hospital.
ISCUSSION
Fine-needle aspiration of various organs has proved merit,
ytology of melanoma nodules is reported in the literature,
jt is not practiced widely.' There now are reports of
tological diagnosis of the primary skin lesion as well.2-3
ecurrent melanoma in subcutaneous nodules and nodes
’ten poses no problem to the cytopathologist. The large
alignant cells and pigment can be seen. Complications are
w with fine-needle aspiration biopsy and metastatic seeding
is been shown to be virtually nil. In these nine cases
(Table), needle aspiration established a rapid diagnosis
which helped in decision making. Several biopsies led direct-
ly to more radical surgery — a few negated the need for open
surgical biopsy, and in two with occult primaries, the
pathology was suggested prior to histological sectioning.
Therefore, fine-needle, aspiration biopsy is a useful tool in
patients with metastatic malignant melanoma.
REFERENCES
1. Hafstrom L, Hugander A, Jonsson P, et al.: Fine-needle aspira-
tion cytodiagnosis of recurrent malignant melanoma. J Surg Oncol
15:229-234, 1980.
2. Woyke S, Domagala W, Czerniak B, et a!.: Fine-needle aspira-
tion cytology of malignant melanoma of the skin. Acta Cytol
24:529-538, 1980.
3. Fontaniere B, Noel P, Mayer M, et al.: The place of
cytodiagnosis in black tumors of the skin: Its value and limits.
Pigment Cell Basel, Karger 2:239-245, 1976.
/OL. 81— NUMBER 2— FEBRUARY 1984
137
MEDICAL HISTORY AND AR1
H
The Art of Banting
■
:
ARTHUR KROSNICK, M.D., Lawrenceville*
Sir Frederick G. Banting, Nobel Laureate for the discovery of insulin,
was also an amateur artist, an art collector, and a friend and admirer
of Canadian artists. An original watercolor sketch on the cover of
this issue provides a perfect reason to discuss the art of Banting.
«
.
it
it
Ii
I
if
ii
ill
ii
*
Our cover is a publication first — it
represents an unpublished original
painting by Sir Frederick Banting,
codiscoverer of insulin and a 1923 Nobel Prize recipient. The
watercolor sketch is owned by Sylvia Swern, the widow of
Dr. Nathan Swern, a New Jersey diabetologist, who died
July 27, 1958.
“Banting dabbled in paints at an early age and made
creditable pictures as a schoolboy. Then he busied himself
with other things and the talent was apparently buried and
forgotten. During the rueful year in London [Ontario] he
resumed his boyhood's hobby and improved the long inter-
vals of waiting with fresh excursions into the delectable
realms of art. He battled ennui with palette and brush. He
forgot his dashed hopes and his hobbling practice as he
squeezed blobs of colour from his paint-tubes.”1
This description refers to the period between completion
of his training as an orthopedic surgeon when he was trying
to establish a practice and his research into the elusive pan-
creatic hormone. Paintbrushes once more were taken out:
“Banting once slipped away from a medical convention in
Montreal and escaped to the mountain for a half a day of
indulgence in the quiet luxury of painting; this was not an
isolated instance of his guilty truancy.”2
Banting’s debut as an artist occurred in January 1925 when
two of his oil paintings were displayed in the Hart House
Sketch Club exhibition. His friend and mentor was A.Y.
Jackson, a Canadian artist and founder of the “group of
Seven,” with whom Banting had a “most enthusiastic and
lasting attachment.” This group of professional artists be-
came his intimate friends. Jackson said: “He knew many ol
the artists. He was very welcome in art circles. He became;
a very popular member of the Arts and Letters Club and
was a good friend to the young people in the Art Students’:
League. He was generous in his admiration and never al-
lowed his eminence in science to give weight to his opinions
of questions of art.”1
Landscape with figures was the subject which interested
Banting the artist most.1 Jackson and Banting made numer-
ous sketching expeditions together, the first of which was to
St. Jean Port Joli on the south shore of the St. Lawrence
in March 1927. Jackson was not unamused by the reactions
of his protege: “There was no sign of spring. It was cold
and windy and very exposed country. We would crouch
behind barns and rail fences to sketch. He was almost frozen
stiff every day, but he struggled with frozen paint and Fingers.
His only comment on one bitterly cold day was, ‘And I
thought this was a sissy game.’ ”'
The subject of our cover picture appears to be St. Irenee
in Quebec; it was probably painted in 1930 or 1931. 4 A
painting similar to the Swern watercolor was owned by
C.A.G. Mathews and was listed as item 51 in a catalogue
of an exhibition entitled, “Banting as an Artist,” a collection
of sketches by Sir Frederick Banting (1891-1941) at the
Academy of Medicine, Toronto, October 21-30, 1971.
*Dr. Krosnick is a diabetologist and Editor, The Journal, MSNJ.
Correspondence may be addressed to Dr. Krosnick, MSNJ, Two
Princess Road, Lawrenceville, NJ 08648.
138
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
How did Nathan Swern acquire the painting which rests
■omfortably on the wall of Mrs. Swern’s apartment in Tren-
on? Dr. Swern graduated from New York University and
hen from Jefferson Medical College in 1922. He was a
□iplomate of the American Board of Internal Medicine, a
Fellow of the American College of Physicians, President of
he Mercer County Medical Society, Chairman of the Mercer
tFounty Diabetes Detection Committee, and member of the
Board of Governors of the New Jersey Diabetes Detection
(Committee and of the American Diabetes Association.
Dr. Swern met Dr. Banting at a diabetes meeting in New
York between 1931 and the onset of World War II. (Banting
died in a plane crash in Newfoundland enroute to England
on February 20, 1941.) Banting had spoken of the French
.'statesman Georges Clemenceau as having lived to age 88
with diabetes, which purportedly made him the oldest living
diabetic until his death in 1929. Banting wanted to learn of
other such elderly diabetics and was very pleased to hear
from Dr. Swern of a patient of his, a Mr. Bonner from
Trenton, who was over 90 years of age. Swern and Banting
apparently saw each other on occasions and, as a gesture
of friendship, Banting gave the sketch to Dr. Swern:2 “He
did exhibit in some of the exhibitions but was always afraid
[that he got in on account of his reputation as a scientist
rather than as a painter, so after a while he stopped sending.
His paintings are scattered all over the place. To anybody
who admired one of his paintings he would say, ‘Oh, well.
you can have it.’ ” 3
On February 21, 1943, the second anniversary of the death
of Sir Frederick was memorialized by an exhibition of his
paintings, drawings, and wood carvings at the Art Gallery
of Hart House at the University of Toronto. The exhibition
contained all of the paintings by Banting which were known
to exist: “An attempt was made to discover every piece of
Sir Fredericks’ artwork in Canada, the United States, Great
Britain, or elsewhere, and to include it in the list at the end
of this book. If some have been missed, it is hoped that
owners will communicate with the warden of Hart House
in order that the record may be as complete as possible.”4
Obviously, the Swern watercolor sketch was not reported,
but it has provided the impetus to describe and discuss the
art of Sir Frederick Banting. This side of the great scientist
was unknown to most of his admirers and to the current
generation of American physicians. Talent comes in clusters
and this Nobel Faureate left the world a legacy from his
scientific and artistic gifts of God.
REFERENCES
1. Stevenson L: Sir Frederick Banting. Toronto, Canada, The
Ryerson Press, 1946, pp. 231-239.
2. Swern S: Personal communication, 1983.
3. Jackson AY: Memories of a fellow artist. Frederick Grant
Banting. Canad Med Assoc 92: 1077-1082, 1965.
4. Jackson AY: Banting as an Artist. Toronto, The Ryerson Press,
1943.
VOL. 81— NUMBER 2— FEBRUARY 1984
139
IMPAIRED PHYSICIANS PROGRAM
Advocacy
DAVID I. CANAVAN, M.D., Lawrenceville*
apei
)(li'
It'
■;
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list
sm
:v
T
he final phase of our program for
the rehabilitation of our impaired
colleagues requires the commitment
of a significant amount of time, effort, and ingenuity. Re-
turning our recovering physician clients to their rightful
place in the medical fraternity is no small task.
In my travels around the state I have encountered three
common myths about physicians:
Myth 1: Physicians are exempt from the diseases that we
consider “impairment.”
Myth 2: If the physician, in contradiction to myth 1, does
acquire one of these diseases, the therapeutic process is not
expected to work.
Myth 3: If the physician, in contradiction to myth 2,
manages to succeed with the therapeutic process, that phy-
sician is not entitled to return to the ranks of the profession.
In support of myth 3, there are several attitudes that
prevail around the state.
The first attitude is that physicians who fall victim to these
diseases have become professional “outcasts,” “moral
lepers,” or “untouchables.” They often are looked upon as
a disgrace to the profession rather than as human beings who
happen to be physicians and who are the victims of diseases
that they never wanted in the first place.
The next attitude is seen more commonly in our dealings
with hospital administration. Here the concern has to do
with the “public image” of the institution that permits a
doctor with a history of impairment to return to its staff.
The third attitude that also is prevalent suggests that the
impaired physician who is recovering should prove himself
at another institution and after succeeding there then may
be worthy of consideration at the original hospital.
In my 28 years in the field of alcoholism and drug abuse,
I constantly have been amazed by my “recovering” patients.
The substance abusers that I have treated are some of the
finest people I know. I used to think that the Creator, in
a spirit of justice, had endowed these folks with some special
qualities to make up for the fact that they had been awarded
a disease that they did not want. As my experience increased,
I came to realize that these were simply fine people to start
with. When their disease was controlled, the qualities and
talents that always were there began to reappear.
r
7.
r
The same experience is there with our recovering physicis „(
clients and I can testify that these doctors are by no meai
second-class persons or physicians.
The attitude of hospital administration about the “publ
image” of the hospital being tarnished by accepting an a\ tj
propriately treated physician back to its staff is a contradii :,f
tion to the entire mission of the hospital to restore patien
to health. How do we preach the doctrine of recover
through appropriate treatment and deny the product of a\
propriate therapy the right to return to the staff? Hospita
can and should be criticized for denying the existence c
“impairment” in their staff and for failing to take apj
propriate action when it exists. No one can justly criticiz
a hospital that restores an appropriately treated physicia
to his rightful place on the staff. It seems to me that th
“public image” of the hospital is more in the eyes of th
administrators than in the eyes of the community. As far a
the third attitude is concerned, there is no “St. Elsewhere’s
in the real world. If an impaired physician is to be returned
to the ranks of the profession, the ideal place is at th
institution where the “fall from grace” occurred. There ma;
be occasional exceptions to this general rule. However, th'
attitude that it is someone else’s responsibility to assist ii
this phase totally is unacceptable.
In the role of “advocate” for program clients, we fine
ourselves in many different arenas.
1. The State Board of Medical Examiners. The Impairec
Physicians Program enjoys an excellent relationship with the
State Board of Medical Examiners (SBME). Our good rela
tionship is based on mutual trust and a reputation for integri
ty. We recognize the legal and moral responsibilities of th«
SBME to protect the public welfare and the SBME rec
ognizes our concern for therapeutic intervention in the legit
imate illnesses of our clients. These two positions not always
are in conflict, and experience has shown that when both
of us work together, in harmony, we can both achieve our
individual goals quite comfortably.
Our role here is to assist the SBME in delineating the
*Dr. Canavan is Medical Director, Impaired Physicans Program.
Correspondence may be addressed to Dr. Canavan, Medical Society
of New Jersey, Two Princess Road, Lawrenceville, NJ 08648.
140
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
i
kjysician’s impairment, and assessing the part that it may
]|ve played in the problems that have brought the physician
I fore the SBME. It is important that we document the
ibrapeutic measures that have been employed to treat the
:ecific impairment, and also to present whatever evidence
i available to demonstrate the continuing participation of
L; physician in our ongoing therapeutic and monitoring
t deavors.
On several occasions we have been able to submit a treat-
I mt/rehabilitation/followup proposal to the SBME for on-
'ing management of a particular problem that has been
cepted and implemented in its entirety.
2. The Malpractice Insurance Companies. Because of the
j ase liaison that our program has with the malpractice
rriers who generously provide two-thirds of our operating
idget, we have been able to defend effectively the right of
me of our clients to have their malpractice coverage con-
t.iued or restored. We also are able to provide ongoing
, )cumentation of recovery when that information is neces-
ry to continue coverage.
3. Hospital Credentials Committees. Physicians who are
,e victims of one of the diseases of impairment often run
to difficulty with credentials committees. It is an important
art of the task of the medical director to appear before such
bmmittees to educate the committee about the nature of the
npairment, its identification, its appropriate and effective
'eatment, and of the rights of the recovering phy-
cian to be returned to an appropriate level of staff privi-
es-
We are in a position to advise the committee concerning
ppropriate safeguards that may be built into the appoint-
ment or reappointment agreement that will provide protec-
on to hospital patients in the event of further impairment.
Ls an example there are specific measures in the area of urine
monitoring that virtually can assure that a recovering drug-
abusing physician cannot return to his drug abuse without
prompt detection at the hospital.
4. Hospital Boards of Trustees. Most often our role here
involves education of the trustees about appropriate treat-
ment for the impaired physician and the program of the
Medical Society of New Jersey for the ongoing supervision
of their rehabilitation. Once again, we can assist the hospital
board in exercising their stewardship by developing
protocols for the appropriate documentation of the physi-
cian’s continuing treatment and recovery.
5. Employment. One of the most difficult areas of our
involvement is in the effort to assist our clients in finding
appropriate employment in the field of medicine so as to
return their own self-esteem and at the same time to satisfy
the limitations of the SBME. There is nothing more frustrat-
ing than to see a perfectly capable physician, effectively
treated for his illness, who remains idle at home because he
cannot find employment either because of the restrictions on
his license or the unwillingness of medical employers to take
a chance on a “dark horse.”
6. Economic Issues. While this is not a routine area of our
involvement, there is an occasional case in which advocacy
involves assisting a recovering physician in doing a realistic
analysis of his current economic situation and working out
an effective economic strategy to survive a period of im-
paired income.
There are other more subtle and less formal ways in which
we “go to bat” for our clients in their uphill battle to regain
good health, equanimity, community and professional accep-
tance and, above all, self-respect.
This article concludes the series on the Impaired Phy-
sicians Program. Future articles will deal with a review of
the current “state of the art” in some of the specific impair-
ments; policy issues and dealing with impairment; and a
review of specific problem cases of an educational interest.
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the “con-
spiracy of silence” that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle” on a suffering colleague is indeed an AC I OF LOVE!
Call Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
yOL. 81— NUMBER 2— FEBRUARY 1984
141
Housing Application
218th ANNUAL MEETING
THE MEDICAL SOCIETY OF NEW JERSEY
MAY 3-6, 1984
Single
Twin
Suites
Resorts International
(headquarters hotel)
$80.00
$80.00
$171/$250
Harrah’s Marina Hotel Casino
$75.00
$75.00
World International Hotel/Motel
$58.00
$58.00
Lafayette Motor Inn
$58.00
$58.00
Rates subject to 12% state and local taxes; tax subject to change.
All hotel reservations for the 218th Annual Meeting of MSNJ will be handled by the Atlantic City Convention
Bureau. Please send your housing application with your 1st. 2nd, and 3rd choices directly to the Bureau, 16 Central
Pier, Atlantic City, NJ 08401. All Delegates and Members are urged to make their hotel reservations early. Blocks
of rooms will be available at Resorts International (headquarters hotel), Lafayette Motor Inn, World International
Hotel/Motel, and Harrah's Marina Hotel Casino. The cut-off date for reservations will be April 6, 1984. Reservations
cannot be guaranteed after this date. No Saturday arrivals please. All registrants will be charged for three nights:
Thursday, Friday, and Saturday, May 3, 4, and 5, 1984.
MAIL THIS APPLICATION DIRECTLY TO THE ATLANTIC CITY CONVENTION BUREAU
16 Central Pier
Atlantic City, NJ 08401
Please list 1st, 2nd, and 3rd choices; confirmation will come directly from hotel.
1st Choice 2nd Choice
3rd Choice
Accommodations desired: □ Single □ Twin □ Suite Parlor & 1 Bedroom
□ Suite Parlor & 2 Bedrooms
Name __
Address
City State Zip
Phone
Will arrive Time Will depart Time
date date
□ Check if Official Delegate County
142
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
DOCTORS' NOTEBOOK
rustees’ Minutes
ecember 18, 1983
A regular meeting of the Board of
•ustees was held on December 18,
83, at the Executive Offices in Law-
nceville. Detailed minutes are on file
th the secretary of your county medi-
1 society. A summary of significant
tions follows:
eport of the President . . .
) Meeting with State Commissioner of
ealth . . . Received a report from the
cond meeting of representatives of
1SNJ with J. Richard Goldstein, M.D.
irected that the appropriate protocol
fe developed for use by the Department
f Health in continuing the study of the
!:admission rate experienced through
irly discharge of patients under the
i>RG method of reimbursement.
i) 1985 Annual Meeting . . . Approved
le following recommendation:
That the 1985 Annual Meeting of the
ledical Society of New Jersey be held at the
.mericana Host Farm Resort and Con-
;rence Center in Lancaster, Pennsylvania.
teport of the Executive Director . . .
1) Paid 1983 Membership . . . Noted
hat paid membership as of November
0, 1983, was 7,506.
2) Financial Statements . . . Approved
he financial statements for the period
nding November 30, 1983.
3) State Board of Medical Examiners
SBME) Proposed Rule on Laetrile . . .
Directed that the SBME be urged to join
vith MSNJ and prohibit the use of
aetrile in New Jersey.
4) Fee for Service — Pathology/TEFRA
Regulations . . . Agreed to adopt the po-
rtion that the signature of hospital-
ised physicians must be required on
iny form which includes either mone-
ary values or distribution formulas of
3art A and Part B components before
he form is filed with governmental
igencies, intermediaries, carriers (or any
rthers to whom the form is sent), and
:hat appropriate bilateral discussions
ind agreements should be reached
Defore the form is signed.
5) Blue Ribbon Ad Hoc Health Care Fa-
:ility Committee . . . Noted that the Ad
Hoc Committee voted six to two to in-
clude physicians in the certificate of need
process for equipment expenditures ex-
ceeding S400,000. Noted that legislation
will be required to effect the inclusion of
a physician’s private practice under the
certificate of need requirement and
MSNJ will be informed of all develop-
ments in this regard.
Academy of Medicine of New Jersey
(AMNJ) . , . Received as informative the
written monthly report from Paul J.
Hirsch, M.D., President of AMNJ (see
page 145).
Committee on Medical Education . . .
Workshop on Surveying Techniques . . .
Approved the following recommen-
dation:
That the Medical Society of New Jersey
consponsors with the Academy of Medicine
of New Jersey a surveying techniques work-
shop for directors of medical education and
other personnel in New Jersey hospitals in-
volved in continuing medical education.
Special Committee on Long-Range Plan-
ning and Development . . .
(1) Direct Candidacy for Elective Of-
fice— Substitute Resolution #5 . . . Re-
ferred back to the Committee for re-
wording and itemization the following
recommendation:
That the Nominating Committee, with
input from the Board of Trustees, develops
a slate of two or three candidates for the po-
sitions of President-Elect, First and Second
Vice-Presidents, Secretary, Treasurer, and Ju-
dicial Councilors. (Trustee positions were de-
leted because of a subsequent recommen-
dation made by the Committee.
(2) Dues Discount for Medical School
Faculty with Less than Six Years of Ser-
vice . . . Disapproved the following rec-
ommendation:
That full-time faculty members, with less
than six years of service, be granted a 25
percent discount until they achieve six years
of service at the University of Medicine and
Dentistry of New Jersey. The discount would
not apply to department chairmen, assistant
dean's, or other senior positions within the
administration and faculty.
(3) Composition of the Board of Trustees
. . . Disapproved the following rec-
ommendation after much discussion:
That the present election process of the
Board of Trustees by the House of Delegates
be changed and that each county medical so-
ciety have the responsibilty to elect or appoint
one Trustee, with the provision that any
county with more than 750 active members
shall be entitled to an additional Trustee, with
a limitation of two Trustees from any given
county. (If approved by the Board of
Trustees, the recommendation should be for-
warded to the Committee on Revision of
Constitution and Bylaws for development of
an amendment to the Bylaws.)
(4) Demographic Study of Membership
. . . Approved the following recommen-
dation:
That the Board of Trustees contacts the
New Jersey specialty society groups involved
(family practice, pathology, psychiatry,
anesthesiology, and general surgery), and the
New Jersey medical schools, for comment
and suggestions with regard to the possible
need for physicians in these areas as shown
by the statewide age study.
(5) Review of MSNJ’s Committee Struc-
ture . . . Approved the following rec-
ommendation:
That the Committee on Long-Range Plan-
ning and Development be charged with com-
pleting a review of the committee structure of
the Medical Society of New Jersey.
Old Business . . .
Appointment of a Committee to Study
Peer Review Organization (PRO) . . .
Empowered the President to appoint a
committee to study PRO and the possi-
bility of MSNJ applying for agent
status.
New Business . . .
Seating of State Medical Society Presi-
dents at Meetings of the AMA House of
Delegates . . . Directed that the Commit-
tee on Revision of Constitution and
Bylaws prepare the appropriate amend-
ment to MSNJ’s bylaws stating that the
current president of a constituent medi-
cal association also may be certified as
an additional alternate delegate at the
discretion of each constituent medical
association.
Note: This amendment was adopted at
the 1983 AMA Interim Meeting.
^OL. 81— NUMBER 2— FEBRUARY 1984
143
President’s Column
Alexander D. Kovacs, M.D.
Sometimes we are our own worst
enemy. We wonder why we do not get
respect and are thought of as being
money hungry and lacking concern for
our patients.
Have you ever stood back and ob-
served yourself through another’s eyes?
Introspective analysis can help your pa-
tient relations. Observe your telephone
manners and those responsible for your
messages or appointments. Are you or
your associates curt, unsympathetic, or
unaccommodating? Are you or your as-
sociates courteous, compassionate, help-
ful, and informative?
Alexander D. Kovacs, M.D.
As an example, take appointment de-
lays. Patients perceive their time as just
as important as yours. If there is going
to be more than a 20-minute delay in
office appointments, does your assistant
or nurse explain the problem and offer
to change the appointment or call to
delay the later ones?
Are you stand-offish or grouchy or
are you pleasant, permitting the patient
to ask questions and to participate in
treatment decisions? Do you make sure
he/she understands how to take the
medication? Do you allow your medical
assistant to reinforce your instructions
or to ask patients if they understand
what they are to do? Do you explain the
reason for the tests you plan to order
and their possible costs? Do you come
across like “big daddy” telling the child
what to do? Is your “God complex”
showing again?
The telephone manners of your staff
may make or break an office. After all,
this is the first and last contact with your
office. No matter how good a doctor
you are, first impressions are lasting!
Listen in on your front office oc-
casionally. A missed message or poor
communication can lead to a malprac-
tice suit.
Does your front office handle fee in-
formation and bill collecting properly
without antagonizing the patient? Does
your staff help patients fill out their in-
surance forms even though you expect
payment in cash or check? Perhaps you
could use “super bills” which are at-
tached to their insurance forms. This en-
tails less work for your assistant.
Encourage your assistant to join and
attend meetings of the Medical Assis-
tants Association. In fact, pay the dues.
Do you explain hospital charges to
your patients? Are you sympathetic if
the patient has a serious disease? This
may be old hat to you but may be terrify-
ing to the patient. I dare say we will not
face our own demises with any more
equanimity than our patients show.
We can harvest complaints about our
concern for the hospitalized patient. The
most common complaint is that the doc-
tor only came in for a few seconds, said
hello, and rushed right out. Why not
enter the room leisurely (even though
you may be in a hurry), sit down on a
chair or the bed, hold the patient’s hand
or forearm, and talk to her/him. Take
your chart into the room and write on
it right there in front of the patient while
you are discussing his or her progress
and show some of the test results. You
have to look at the chart anyway, so
show the patient the hospital visit is
more than just running in and out of the
room. If it is a social visit or if the pa-
tient is under someone else’s care, do not
charge a visiting fee. Do not charge an
“admission fee” to the hospital — instead
a “time spent for history and physical
fee” or “treatment evaluation fee.” The
terminology “admission fee” creates pa-
tient resentment.
If you are a consultant, tell the patient
who you are, why you were called, and
that there will be a fee involved and
whether insurance will cover the visit.
Nothing is more distressing to a patient
than to receive a bill for a large consul-
tation fee when he or she does not know
who the consultant is or how this doctor
got involved.
The art of the practice of medicine or
surgery goes beyond technical skill. The
cognitive skills in medicine are more
than observation and evaluation.
Cognitive means “to recognize, be
aware, and be sensitive to.” Let us try
to be cognitive not just of the patient’s
disease but of that very human person
who is the patient.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
According to a report compiled by t
Office of the Registrar and presented
the university’s Board of Trustef
female enrollment at UMDNJ has co
tinued to rise steadily since 1969. Fort "
four percent of UMDNJ’s 2,401 st
dents are women, as compared to a 3
percent enrollment in 1969.
There are 250 women (37.7 percent)
UMDNJ-New Jersey Medical Schocr
which has for several years maintain* ;
one of the highest percentages of fema ; *
medical students in the country. T1
largest single group of women student
433, is at the School of Health-Relate' J
Professions.
The remaining breakdown is as fo
lows: 92 female students at New Jerse '
Dental School; 48 at the School of 0: 1
teopathic Medicine; 124 at Rutgei
Medical School, Piscataway; 29 tP
Rutgers Medical School, Camden; 43 £ ;
the Graduate School of Biomedical Sci :
ences; 7 in the postgraduate programs c 1
New Jersey Dental School; and 46 in th
graduate public health program offerei ’
jointly by Rutgers Medical School an ;
Rutgers, the State University.
UMDNJ has been awarded $400,001
to establish a laboratory on its Newarl
campus to further research and patien
care efforts in the battle against acquire*
immunodeficiency syndrome (AIDS)
The funds, part of the total $530, 00(
appropriated this summer by the State
Legislature for a comprehensive AIDS
program, will be used for staff anc
equipment for the laboratory. The most
important piece of equipment will be z
quarter-million dollar Fluorescence Ac-
tivated Cell Sorter that incorporates
computer and laser technology and is
capable of analyzing 5,000 blood cells
per second.
Two standard laboratories currently
are being transformed into a 1 ,800
square-foot laboratory and “P3” con-
tainment facility to be called the Pedi-
atric Cellular Immunology Laboratory.
The P3 status is the second highest desig-
nation by the federal government for fa-
cilities involved in research with possible
contaminants.
The laboratory, to be completed in
1984. will be located in the Medical Sci-
ence Building and will be under the
direction of James M. Oleske, M.D. Dr.
Oleske, a prominent expert on AIDS
who was one of the first investigators to
identify the disease in children, is as-
sociate professor of pediatrics with a
144
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
tint appointment in preventive medi-
ne and community health at UMDNJ-
ew Jersey Medical School.
The first pregnancy resulting from
ew Jersey's only in vitro fertilization
rogram was announced by Dr. Ek-
;hard Kemmann, director of the pro-
gram and chief of the division on repro-
uctive endocrinology and fertility at
liddlesex General-University Hospital,
Mew Brunswick. The program, jointly
)onsored by the hospital and UMDNJ-
.utgers Medical School, where Dr.
iemmann is associate professor, began
dmitting patients in May 1983.
UMDNJ has joined Rutgers, the State
Jniversity, to begin the first Masters of
ublic Health Program in the state with
0 students enrolled in the new program.
Administered by the Department of
Environmental and Community Medi-
jiine, UMDNJ-Rutgers Medical School,
/ith courses held at the Rutgers-New
trunswick campus, the program offers
major in one of four specialty areas;
nvironmental health; health educa-
ion/behavioral sciences; occupational
lealth; and biostatistics. Planned for the
pring semester is a specialty in health
are organization and administration,
vith epidemiology scheduled for the
984 to 1985 academic year. Other
pecialty areas will be developed to meet
tudent needs.
New Jersey is an important laboratory
'or the study of the relationship between
ndustrialization, urbanization, and pub-
ic health. This program, which stresses
mvironmental and occupational health,
vvill not only help meet the state's need
for health professionals, but also will
address critical public health problems
in our state.
VISNJ Auxiliary
Sale Wayman
Resident
As promised several months ago, I
A'ill elaborate on the AMPAC Political
Education Conference held in Washing-
ton, D.C., this past fall. “Participation
84” was the theme and AMPAC is en-
couraging the active involvement of
AMA members and their families in the
1984 presidential campaign. In so doing,
AMPAC is seeking to promote better
government and to ensure the concerns
of the medical profession. The AMA
directly will help in the process by com-
mitting such resources as training sem-
inars, publications, meetings, and
special communications. It also is bring-
ing these seminars to the states, with
one, hopefully, in New Jersey this
spring.
While in Washington, we learned
something of “party leadership" from
Senators Ted Stevens (Alaska) and
Lloyd Bentsen (Texas). A feisty Senator
Robert Dole gave us insight into what
is happening in Washington and we were
let in on some White House information
from Ed Meese, counselor to the Presi-
dent. All these “big guns” of politics had
one clear message; if we, the medical
profession, do not become involved in
politics, we will be forgotten. It is the
squeaky wheel that gets the oil!
It was very gratifying to see in the
November AMPAC Sustainer that one
of New Jersey's physicians is doing an
outstanding job of getting involved. Dr.
Peter Amirata, President of Essex Coun-
ty, has marshaled a steering committee
of physicians to help raise membership
and funds — in four months he has been
able to raise $17,000 and obtain 175
members in Essex County. This is in
comparison to last year's state figure of
$14,000.
The Auxiliary is working with its
members for more participation, but let
us all try to get involved.
AMNJ Report
Paul J. Hirsch, M.D.
President
During the past year the Academy of
Medicine has continued to expand its
primary roles, and has added a number
of significant new member benefits.
The Academy of Medicine is the
statewide organization responsible for
accreditation of continuing medical
education in New Jersey. Any meeting,
conference, or program submitted for
approval is evaluated carefully by the
Academy staff, and by the Education
Committee. The Academy maintains
high standards for the quality of con-
tinuing medical education in New Jer-
sey.
In addition, the Academy of Medicine
sponsors educational programs to meet
the needs of practicing physicians. These
programs include the roving symposia,
or major symposia series, individual
programs, and programs sponsored in
association with the Medical Society of
New Jersey, the specialty societies, and
other organizations and institutions in
our state. In all of these, the quality ol
education is high, and the cost to phy-
sicians has been kept quite moderate.
These educational activities of the
Academy of Medicine are supported by,
and run by, the practicing physicians of
New Jersey. In planning programs, the
Academy recognizes and evaluates
educational needs and educational
wants of the medical community. The
Academy now is in the process of de-
veloping a more formal process to assess
these wants and needs.
The Academy of Medicine provides
administrative and secretarial services
for most of the specialty societies in New
Jersey. Twenty-six societies now utilize
these services. This process has brought
together many of these organizations,
and has helped to unite the physicians
in different specialties, in many common
purposes.
Despite the success of the Academy of
Medicine, we continue to improve our
programs, and to seek additional ways
in which to better serve our membership.
During the past year, we have initiated
a computerized program to record the
CME credits of AMNJ members; twice
each year, members receive a com-
puterized printout of all courses attend-
ed, whether sponsored by the Academy
or not. We now send a useful monthly
program booklet, listing educational
programs available in New Jersey, in-
dexed by specialty. We have initiated the
“First Wednesday" program, to bring to
the Academy speakers of significance on
socioeconomic topics. We are expanding
our Speaker’s Bureau program to in-
clude a separate Speaker's Bureau for
community groups; organizations re-
questing medical speakers will be given
the names of Academy members in their
areas. The Academy continues to
provide excellent library services
through the University of Medicine and
Dentistry of New Jersey.
Among other important and worth-
while functions of the Academy of
Medicine, I would note particularly the
annual Edward J. Ill Award to an
outstanding physician in New Jersey.
We believe that it is important to rec-
ognize leadership in the medical com-
munity. Although membership in the
Academy is considered in determining
this Award, all physicians are eligible
and may be nominated.
Finally, the Academy strongly sup-
ports the purposes and tasks of the
Medical Society of New Jersey. Indeed,
the identification of the Academy of
Medicine with the Medical Society has
been so great, that many members of
MSN.I have felt that they are “automati-
cally” members of the Academy. This is
not so. Although the Academy is con-
sidered “the teaching arm of the Medical
Society of New Jersey," it is a separate
145
VOL. 81— NUMBER 2— FEBRUARY 1984
organization, with separate member-
ship. We would encourage all members
of MSNJ to be Fellows of the Academy,
and to support quality continuing medi-
cal education in our state, based upon
the needs of the practicing physician.
Task Force on Feta!
Alcohol Syndrome
The Chairman of the Subcommittee
on Newborn Record Keeping reported
that a Task Force on Fetal Alcohol Syn-
drome was formed under the New Jersey
Division of Alcoholism. The Task Force
will plan strategies to address the prob-
lems of fetal alcohol syndrome by de-
veloping a systematic approach toward
accurate identification of women-at-
risk, and appropriate intervention and
treatment strategies for mothers and
children.
The following recommendation was
approved by the Board ofTrustees: That
the Medical Society of New Jersey en-
dorses the educational goals of the Task
Force on Fetal Alcohol Syndrome and
urges all physicians caring for women of
childbearing age to bring the dangers of
drinking to their attention.
Physicians Seeking
Location in New Jersey
The following physicians have written to the
Executive Offices of MSNJ seeking infor-
mation on possible opportunities for practice in
New Jersey. The information listed helow has
been supplied by the physician. If you are
interested in any further information concern-
ing these physicians, we suggest you make in-
quiries directly to them.
ANESTHESIOLOGY— Jan Charles Hor-
row, M.D., 131 Pond Brook Rd., Chestnut
Hill, MA 02167. Pennsylvania 1977 Board
certified. Group, academia, HMO. Avail-
able.
CARDIOLOGY — Aubrey Orrin Lewis,
M.D., 200 Carman Ave., Apt. 2 1 - F, East
Meadow, NY 11554. SUNY-Syracuse
1979. Also, general internal medicine.
Board certified (IM). Solo, partnership,
group, academia (cardiology). Available
July 1984.
Lt. Gary P. Schwartz, M.D., USAF, 8
Lodge Dr.. Rockville, MD 20850. SUNY-
Upstate 1968. Board certified. Single
specialty, multispecialty group, partner-
ship. Available September 1984.
FAMILY MEDICINE— Jaime F. Lara,
M.D. 6045 Palisade Ave., West New
York. N.l 07093. Seville (Spain) 1979.
Board eligible. Partnership or institutional-
ly based. Available.
GASTROENTEROLOGY — Albert M.
Harary, M.D., 2121 N. Bayshore Dr., Apt.
1001, Miami, FL 33137. Columbia 1978.
Also, general internal medicine. Board
certified (IM). Group, partnership, solo.
Available July 1984.
P. Kothanda Raman, M.D., 9 Lake Ave.,
Apt. 5A, East Brunswick. NJ 08816.
Stanley Medical College (India) 1977.
Board eligible (IM). Also internal medi-
cine. Partnership, group, solo. Available
July 1984.
INTERNAL MEDICINE— Nicholas Bertini.
M.D., 663 Hudson Ave., Albany, NY
12203. SUNY-Buffalo 1980. Board eligible.
Group, partnership, solo. Available June
1984.
Harold J. Brown, M.D., 260 Eggerts Rd.,
Lawrenceville, NJ 08648. UMDNJ 1982.
Primary care clinic, HMO, group, partner-
ship. Available July 1985.
Palamadai S. Duraiswami, M.D., 64-A
Oneida Ave., Centereach, NY 11720.
Stanley Medical College (India) 1976.
Board eligible. Available.
Elliott Friedman, M.D., 25 Penny La., Bal-
timore, MD 21209. SUNY-Syracuse 1978.
Subspecialty, endocrinology. Board
certified (IM); board eligible (endo-
crinology). Group or partnership (both
specialties). Available July 1984.
■ it
Lee W. Hoffer, M.D., 1017 East 80th St
Brooklyn, NY 11236. Rome (Italy) 1 98(
Solo, partnership, group. Available.
Arvind Mehta, M.D . 8051 N. HanoverSt
Anaheim, CA 92861. Seth G.S. Medic; '1
College (India) 1975. Also, nephrology If
Board eligible Solo, group, associate
Available.
P. Kothanda Raman, M.D., 9 Lake Ave
Apt. 5A, East Brunswick, NJ 088 <
Stanley Medical College (India) 197
Board eligible. Also, gastroenterology '
Partnership, group, solo. Available Jul j
1984.
Steven Wolinsky, M.D., 1404 E. 15 St :
Brooklyn, NY 11230. Case Western Rt 1
serve 1980. Group or partnership. Avail] L
able July 1984.
NEPHROLOGY— Arvind Mehta, M.D.
8051 N. Hanover St., Anaheim, CA 92861
Seth G.S. Medical College (India) 1975 ®
Also, internal medicine. Board eligible
Solo, group, partnership. Available.
NEUROLOGY — Elizabeth Kamenar, M.D.
12701 Shaker Blvd., Apt. 410, Cleveland
OH 44120 Ohio State 1975. Board eligible
Group, partnership, academia. Available;
July 1984.
Robert P. Rubens, M.D., 105 Ward St..
Apt. 204, Seattle, WA 98109. UMDNJ-
New Jersey Medical School 1980. Board
eligible. Available July 1984.
OBSTETRICS/GYNECOLOGY— Alan M.
Askinas, M.D., 1309 Carrollton, Apt. 321,
Metairie, LA 70005. Illinois 1980. Board
eligible. Group, partnership, solo, part
academia. Available July 1984.
Wook Chung, M.D.. 2212 Watterworth
Dr., Kalamazoo, MI 49008. Catholic
Medical College (Korea) 1967. Board
certified Solo, group, partnership. Avail-
able.
Iris E. Dominy, M.D., 108 Pinegate Circle,
Apt. 2, Chapel Hill, NC 27514. Albany
1978. Board eligible. Partnership or group
in metropolitan area. Available July 1984.
OPHTHALMOLOGY— Steven R. Davis,
M.D , 1000 Lakeview Rd., Clearwater, ELI
33516. University of Alabama 1975. Board
certified. Solo or association. Available.
Andrew Gewirtz, M.D., 519 Beach 133 St.,
Belle Harbor, NY 11694. Chicago 1978.
Board eligible. Board certified (pediatrics).
Group or partnership. Available July 1984.
PATHOLOGY— Mark A. Grathwhol, M.D.,
2510 West Tremont Ct., Richmond, VA
23225. NYU 1980. Group. Available July
1984.
Yury Kogan, M.D. 60 Egmont St.,
Brookline, MA 02146. Moscow 1967. Hos-
pital or group. Available July 1984.
PEDIATRICS— Jonathon J Evans, M.D.,
1800 Calvin Ct„ #6, Iowa City, IO 52240.
Univ. of California-San Diego 1981. Board
eligible. Group or HMO. Available July
1984.
Michael J. Foreman, M.D., 2527
Hydraulic Rd., #52, Charlottesville, VA
22901. Hahnemann 1981. Board eligible.
Group or partnership. Available July 1984.
218th Annual Meeting
May 2-6, 1984
Resorts International
Atlantic City
Fill out the Application Form
Page 142
146
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Howard Mintz, M.D., 60 Presidential
Plaza, Apt. 308, Syracuse, NY 13202. Pitts-
burgh 1981. Board eligible. Group or part-
nership. Available July 1984.
jsYCHIATRY— Eric M. Levin, M.D., 43
West 8th St., Media, PA 19063. La Faculte
Libre de Medicine (Spain) 1980. Board
I eligible. Group, institutionally based,
CMH outpatient. Available July 1984.
ULMONARY DISEASES— James Kohan,
M.D., 19 Highmanor Dr., Henrietta, NY
14467. Virginia 1979. Also, general internal
medicine. Board certified (IM). Group,
partnership, solo, institutional. Available
July 1984.
Dinesh Talati, M.D., 66-02 Grand Central
Pkway., Forest Hills, NY 11375. B.J.
Medical College (India) 1974. Board
eligible. Solo, group, partnership. Avail-
able Julv 1984.
A DIO LOGY/ NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon St.,
Apt. 3B, Brookline, MA 02146. Boston
1976. Board certified. Group or partner-
ship. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond Brook
Rd., Chestnut Hill, MA 02167. Med Col-
lege of Pennsylvania 1980. Board eligible.
I Group, HMO, academia. Available.
HEUMATOLOGY— Richard Furie, M.D.,
1 435 E. 70th St., Apt. 8-F, New York, NY
10021. Cornell 1979. Also, general internal
medicine. Board certified (IM). Group,
partnership, solo. Available July 1984.
URGERY, GENERAL— Ramon .1. Gomez,
M.D., 40-71 Gleane St., Elmhurst, NY
1 1373. University of the East (Philippines)
1978. Group or hospital-based emergency
medicine practice. Available.
Ravinder Jagpal, M.D , 3408 Balboa La.,
Apt. 33, Columbia, MO 65201. Rutgers
1981. Also, cardiothoracic surgery. Board
certified (S); board eligible (TS). Group.
Available July 1 984.
SURGERY, ORTHOPEDIC— Jeffrey H.
Charen, M.D.. 155 Lexington St., Apt 15,
Auburndale, MA 02166. Rochester 1978.
Board eligible. Group, partnership, solo
(central or northern NJ preferred). Avail-
able January 1984.
Salvatore Inserra, M.D., 1847 79th St.,
Brooklyn, NY 11214. NYU 1979. Board
eligible. Group, partnership, solo. Avail-
able July 1984.
Richard Lebovicz. M.D., 415 Grand St.,
New York, NY 10002. SUNY-Downstate
1979. Group or partnership. Available July
1984.
Oscar A. Reicher, M.D., 71 Brookwood
Ter., Nashville, TN 37205. Pittsburgh
1979. Solo or group. Available July 1984.
UROLOGY— Joseph G. Colonna, M.D.,
1234 Van Voorhis Rd., Apt. C-6, Morgan-
town. WV 26505. Guadalajara (Mexico)
1 977. Board eligible. Group or partnership.
Available October 1984.
Barlow S. Lynch, M.D., 5145 Linda Lou
Dr., Carmichael, CA 95608. SUNY-Buf-
falo 1977. Board eligible. Partnership,
group, solo, academia. Available July 1984.
A
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
UPO-NICIN't73CfO mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg
Ascorbic Acid 150 mg
Thiamine HCL (6-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPQ-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily
AVAILABLE: Bottles of 100, 500.
LIPO NICINTIOO mg.
Each blue tablet contains:
Nicotinic Acid 100 mg
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily
AVAILABLE: Bottles of 100, 500
Indications: For use as a vasodi
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation Also provides
concomitant administration of
the listed vitamins The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding
Write for literature and samples
(brcAWE THE BROWN PHARMACEUTICAL CO„ INC. p-fI0
2500 West Sixth Street, Los Angeles, California 90057 PDR
likoff cardiovascular institute
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
WEDNESDAY, MARCH 7, 1984
CARDIAC FAILURE
MODERATOR: WILLIAM LIKOFF, M.D.
3 00 CASE PRESENTATION William Likoff, M.D.
3 00 THE PATHOPHYSIOLOGY OF CONGESTIVE FAILURE Irving M. Herlmg, M.D.
4 00 THE OVERT AND SUBTLE CLINICAL MANIFESTATIONS
OF CARDIAC FAILURE Abdulmassih S. Iskandrian, M.D.
4 30 RENAL FUNCTION IN PATIENTS WITH
CARDIAC FAILURE David T. Lowenthal, M.D.
5:00 NEWER DRUGS FOR SEVERE AND
REFRACTORY CARDIAC FAILURE Mariell J. Likoff, M.D.
5:30 PANEL DISCUSSION
LECTURE HALL “A”— 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
“WINE & CHEESE SERVED FOLLOWING CONFERENCE**
University of
Pennsylvania
School of
Medicine
Trends in Clinical Nutrition
Eighth Annual Nutrition Symposium April 3-5, 1984
Dunlop Auditorium, University of Pennsylvania
School of Medicine, Philadelphia
Philadelphia
Veterans
Administration
Medical Center
The purpose of this program is to provide the practicing physician, clinical dietitian, nurse, and pharmacist
with a clinical approach to commonly encountered diagnostic and therapeutic problems in adult clinical nutrition.
Discussion Topics:
Nutrition and Aging, Nutrition in
Liver Disease, Enteral Alimenta-
tion-Alternative Approaches,
Complications of Long-Term
Parenteral Nutrition, Nutrition
and Sepsis, History and Future
of Specialized Nutrition Support,
Anorexia Nervosa, Credentiaiing
of Nutrition Support Profession-
als, Respiratory Considerations
and Energy Expenditure, and
Enteral vs Parenteral Nutrition.
Continuing Education Credits:
Approval has been granted for
credits for dietitians, nurses,
pharmacists, and physicians
Course Directors:
James L Mullen, M.D , Chief,
Surgical Service, Philadelphia VA
Medical Center. Director, Nutrition
Support Service, Hospital of the
University of Pennsylvania,
Associate Professor of Surgery,
University of Pennsylvania
Wanda Hain Howell, R D ,
M Ed., Nutrition Education
Specialist, Nutrition Support
Service, Hospital of the Univer-
sity of Pennsylvania
Registration Fee: $100
Guest Faculty:
Jeffrev Askanazi, M D.
George Blackburn, M D , Ph D
Rex Brown, Pharm D
Frank Cerra, M.D.
Loretta Forlaw, Maj , A.N.C.
David Lipschitz, M.D., Ph D
Carol Mitchell, Ph D , R D
Theodore Reiff, M.D.
Barney Sellers
William Steffee, M.D, Ph D
For Information and
Registration, contact:
Office of Continuing Medical
Education
School of Medicine/G3
University of Pennsylvania
Philadelphia, PA 19104
(215)898-8005
148
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSFU
CME CALENDAR
Ihis list is compiled through the cooperation
if the Committee on Medical Education of the
vledical Society of New Jersey, the Academy
if Medicine of New Jersey, the New Jersey
hapter of the American Academy of Family
5hysicians, and the Office of Continuing Medi-
al Education of the University of Medicine
ind Dentistry. For information on accredita-
ion, please contact the sponsoring organiza-
ion(s), indicated by italics — last line of each
Item.
ANESTHESIOLOGY
Alar.
9 25th Postgraduate Anesthesia Seminar
10 8 A M — Hyatt, Cherry Hill
11 (NJ State Society of A nesthesiologists
and A MNJ)
Apr.
16 Pain Therapy
11:30 A.M.- 12:30 P.M.— Columbus
Hospital, Newark
( AMNJ )
CARDIOLOGY
Mar.
■ 7 Noninvasive Testing in Cardiovascular
Disease
9-1 1 A. M — Middlesex General Hospital,
New Brunswick
( Middlesex General Hospital and A MNJ )
7 Cardiology
14 3-6 P.M. —Overlook Hospital, Summit
21 (Overlook Hospital and A MNJ)
20 Current Therapy of Acute Myocardial
Infarction
12 noon — St. Mary’s Hospital, Orange
( AMNJ )
Apr.
17 Management of Unstable Angina
12 noon — St. Mary’s Hospital, Orange
(AMNJ)
25 Management of Acute Myocardial
Infarction
1-2:30 P.M.— VA Medical Ctr., Lyons
(VA Medical Ctr. and AMNJ)
MEDICINE
Mar.
1 Medical Grand Rounds
9:30 A M.— Newark Beth Israel
Medical Ctr.
( Endocrinology Section. AMNJ)
1 Effects of Stress on Disease
15 Heart Disease, Lipoproteins, and
Nutritional Counseling
1 1 A M — St. Joseph’s Hospital and
Medical Center, Paterson
(St. Joseph's Hospital and UMDNJ)
2 Medical Grand Rounds
1 1:30 A.M. — University Hospital,
Newark
( Endocrinology Section, A M NJ)
2 Renal Conferences in Nephrology
16 4-5 P.M. — UM DNJ-University Hospital,
Newark
( Nephrology Society of NJ and
Nephrology Section, A MNJ)
6 Nutrition Support — Middle Age and the
Elderly
1 1 A.M.- 12 noon — Greystone Park
Psychiatric Hospital
(AMNJ)
7 Medical Grand Rounds
1 1 :30 A M. — VA Medical Ctr.,
East Orange
(Endocrinology Section, AMNJ)
7 Hypertension
1 :30 P.M. —Essex County Hospital Ctr.,
Cedar Grove
(AMNJ)
1 Angina
21 Obstructive Uropathy
1- 2:30 P.M. —Christ Hospital,
Jersey City
( Christ Hospital and A M NJ)
7 Endocrine Conferences
14 3:30-5 P M — Rotates between Newark
21 Beth Israel Medical Ctr., UMDNJ-
28 University Hospital, and United
Hospitals Medical Ctr., Newark, and
VA Medical Ctr., East Orange
(Endocrinology Section, AMNJ)
8 Pain Therapy
2 P.M. —John E. Runnells Hospital of
Union County, Berkeley Heights
(A MNJ)
13 Diet and Cancer
22 Detection and Diagnosis
29 Principles of Patient Management
4- 6 P.M. —Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ) '
13 Blood Banking Seminar
2- 5 P.M. —Rutgers Medical School,
Piscataway
(NJ Blood Services and A MNJ)
15 Current Approaches to Irritable Bowel
Syndrome
5- 6:30 P.M.— Somerset Medical Ctr.,
Somerville
(Somerset Medical Center and A M NJ)
20 Emergency Care — Cardiac Drug
Overdose
1 1 A M - 12 noon— Greystone Park
Psychiatric Hospital
(A MNJ)
20 Hypertension
1 :30-2:30 P.M. —Essex County Hospital,
Cedar Grove
(A MNJ)
20 Regional Nephrology Conferences
' 4.5 p.M. —Academic Health Science Ctr.
(UMDNJ-Rutgers Medical School and
A MNJ)
21 Dermatological Conference
6- 9 p.M. —Rutgers Community Health
Plan, 57 U.S. Hwy. 1, New Brunswick
( UMDNJ-Rutgers Medical School and
A MNJ)
21 Significance and Treatment of Common
Abnormalities in Serum Electrolytes
and/or Acid-Base Balance
28 Antibiotic and Antiviral Agents in an
Office Practice
9-1 1 A M. — Middlesex General Hospital,
New Brunswick
(Middlesex General Hospital and A M NJ)
28 Extended Spectrum Penicillin and
Cephalosporins
10:30 A.M.- 12 noon — St. Mary’s
Hospital, Passaic
(St. Mary 's Hospital and A MNJ)
28 Implications of Clinical Trials on
Management of Mild Hypertension
1-2:30 P.M.— VA Medical Center, Lyons
I VA Medical Center and A MNJ)
28 Dermatology
3-6 P.M. —Overlook Hospital, Summit
(Overlook Hospital and AMNJ)
Apr.
2 Laser Treatment — G!
1 :30 P.M. —Columbus Hospital, Newark
(AMNJ)
4 Medical Grand Rounds
1 1 : 30 A.M.— VA Medical Center, East
Orange
(Endocrinology Section, AMNJ)
4 Alcoholism
1 :30 P.M. —Essex County Hospital Ctr.,
Cedar Grove
(AMNJ)
4 Antibiotic Nephrotoxicity
1-2:30 P.M. — VA Medical Center, Lyons
( VA Medical Center and A MNJ)
4 Hypertension in the Elderly
25 Paget’s Disease
1-2:30 P.M. — Christ Hospital, Jersey City
( Christ Hospital and A MNJ)
4 Cutaneous Manifestations of Systemic
Diseases
11 Medical Treatment of Gallbladder
Disease
18 Osteoporosis and Kidney Stones
25 The Powerful New Role of Monoclonal
Antibodies in Medical Diagnosis and
Treatment
9-1 I A M — Middlesex General-
University Hospital, New Brunswick
(Middlesex General-University Hospital
and A MNJ)
4 Endocrine Conferences
1 1 3:30-5 P.M. — Rotates between Newark
18 Beth Israel Med. Ctr., University
25 Hospital, and United Hospitals Medical
Ctr., Newark, and VA Medical Center,
East Orange
( Endocrinology Section, AMNJ)
5 Medical Grand Rounds
9:30 A M.— Newark Beth Israel Medical
Ctr.
(Endocrinology Section, A MNJ)
VOL. 81— NUMBER 2— FEBRUARY 1984
149
ACUPUNCTURE IN CLINICAL PRACTICE
N Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
January 27-29, 1984 and again the weekend of March 23-25,
1984 at the Barbizon Plaza Hotel, New York City. Co-sponsored
by the International College of Acupuncture & Electro-Thera-
peutics, Its official journal (published by Pergamon Press) the
Heart Disease Research Foundation and the Neuroscience
Dept of Long Island College Hospital, Pharamcology Dept, of
The Chicago Medical School. Also eligible for AMA/CME credit.
For information, contact Y. Omura, M.D., ScD., 800 Riverside
Drive (8-1), NYC 10032. Tel: (212) 781-6262 or (212) WA8-0658,
or Saul Heller, M.D., Tel: (212) 838-7514.
MEDICAL CENTER POSf ~ G Tad U atS
Medical School
March
12-16 Managing Clinical Problems in the Elderly
(Cerromar Beach Hotel/Puerto Rico)
19-23 Seminar in Advanced Rheumatology
26-30 Anesthesiology: Comprehensive Review III
April
26-28 Update in Clinical Dermatology
Information: NYU Post-Graduate Medical School, 550 First
Avenue, New York, NY 10016 (212) 340-5295.
THE ACADEMY OF MEDICINE
OF NEW JERSEY
in cooperation with
SAINT BARNABAS MEDICAL CENTER
presents
a symposium on
“MANAGEMENT OF PATIENTS
WITH LOW VISION”
Saturday, March 31, 1984
8:15 a. m. -4:30 p.m.
at
SAINT BARNABAS MEDICAL CENTER
Livingston, N.J.
The program will provide a complete and practical presen-
tation of all aspects of management of the patient with low
vision, and will include presentations by nationally prominent
speakers on low vision corrections for distance and near;
methods of testing and recording vision; corrections related
to field defects; illumination; optical aids; Corning photo-
cromatic filters; genetic counseling; management of low vision
in children; favorable and unfavorable patients; social, educa-
tional and rehabilitation services for the partially sighted pa-1
tient; and telescopic spectacles. The program is designed for
ophthalmologists, optometrists, opticians and other interested
professionals.
Program Chairman: Gerald Fonda, M.D.
Director, Low Vision Center
Saint Barnabas Medical Center
For further information contact:
EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
Two Princess Road, Lawrenceville, NJ 08648
(609) 896-1717
Eighteenth Annual Main Life Conference
“CURRENT CONCEPTS IN MEDICINE FOR THE
PRACTICING PHYSICIAN”
Thursday, Friday and Saturday May 3, 4 and 5, 1984
VALLEY FORGE HILTON • KING OF PRUSSIA, PA.
Sponsored by
THE BRYN MAWR HOSPITAL
In affiliation with Jefferson Medical College
PROGRAM INCLUDES: • Unknown Fever • Obesity and Anorexia • Hypertension • Arrhythmias • Oliguria • Breast
Cancer • Hormone Therapy • Diabetes • Which Test? • 26 Concurrent Clinics
GUEST SPEAKERS INCLUDE: * Charles A. Kallick, M.D., Cook County Hospital • Richard S. Rivlin, M.D., Memorial
Sloan-Kettering Cancer Center • Arnold E. Andersen, M.D., Johns Hopkins Medical Institutions • Joseph N.
DiGiacomo, M.D., University of Pennsylvania • Alvin F Goldfarb, M.D., Jefferson Medical College • J. Ingram Walker,
M.D., Duke University Medical Center
ACCREDITATION:
AMA
As an organization accredited for continuing medical education, the
Jefferson Medical College designates this continuing medical activity as
meeting the criteria for 20 credit hours in Category I of the Physician's
Recognition Award for the American Medical Association
PMS
AAFP
This program has been reviewed and is acceptable for 20 Prescribed
hours by the American Academy of Family Physicians.
AOA and ACGPOMS approved
FOR INFORMATION WRITE:
HAROLD J. ROBINSON, M.D.
Director, Main Line Conference
The Bryn Mawr Hospital
Bryn Mawr, Pennsylvania 19010
Registration Fee: $185.00
(includes 3 luncheons, cocktails and dinner)
150
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
5 Psychosocial Care and Unorthodox
Cancer Therapies
4-6 p.M. — Institute for Medical Research
Copewood St., Camden
(Institute for Medical Research and
A MNJ I
6 Medical Grand Rounds
1 1:30 A M.— University Hospital,
Newark
( Endocrinology Section, AMNJ)
6 Renal Conferences in Nephrology
20 4-5 P.M. —University Hospital, Newark
( Nephrology Society of NJ and
Nephrology Section, A MNJ )
13 Controversies in the Management of
Otitis Media
8-9:30 A M — Overlook Hospital,
Summit
( Overlook. Hospital and A MNJ)
17 Laser Treatment of Massive
Gastrointestinal Hemorrhage
1 1 A.M - 12 noon — Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric Hospital and
AMNJ )
17 Renal Osteodystrophy
4-5 P.M. —Academic Health Science Ctr.,
New Brunswick
(UMDNJ-Rutgers Medical School and
A MNJ )
18 Substance Abuse and Misuse
8:30 A M - 1 P.M. —Medical Society of
New Jersey, Lawrenceville
(NJ State Department of Health, MSNJ,
and AMNJ)
18 Dermatological Conference
6-9 P.M. — Rutgers Community Health
Plan, 57 U.S. Hwy. 1, New Brunswick
(UMDNJ-Rutgers Medical School and
A MNJ )
18 William P. Burpeau Annual Award
Dinner
6:30 P.M. —The Manor, West Orange
( Urology Section, A MNJ)
24 How Scientific Is Modern Medicine?
7:30-8:30 P.M — Ramada Inn, Exit 135,
Garden State Parkway
( Nephrology Section of NJ and A MNJ)
26 Renal Hemodynamics of Hypertension
1 1 A M.- 12:30 P.M. —St. Joseph's
Hospital, Paterson
(St. Joseph ’s Hospital and Medical
Center and A MNJ )
26 Regional Hospital Meeting
8-10 P.M — Overlook Hospital, Summit
(NJ Gastroenterological Society and
AMNJ)
NEUROLOGY/PSYCHIATRY
Mar.
1 Pharmacotherapeutic Agents in the
Management of Borderline-Personality
Disorders
3 Depression: Differential Diagnosis, and
Newer Methods of Treatment
1-2:30 P.M —Christ Hospital, Jersey City
( Christ Hospital and A MNJ)
8 Advances in Neuroleptic Medication
15 Alone — Yearning for Companionship
12 noon-1 P.M. —Carrier Foundation,
Belle Mead
(Carrier Foundation and A M NJ)
6 Is There a Devil?
8: 1 5-10:30 P.M. — 39 Crescent Ave.,
Passaic
( Essex Psychiatric Seminar and A MNJ)
7 Group Therapy
21 2-3 P.M. — Ancora Psychiatric Hospital,
Hammonton
( A ncora Psychiatric Hospital and A MNJ)
9 Psychiatric Lecture Series
16 1:30-5 P M.— Trenton Psychiatric
Hospital
23 (Trenton Psychiatric Hospital and
30 AMNJ )
14 Anxiety and Neurosis
9-1 1 A.M. —Middlesex General Hospital,
New Brunswick
I Middlesex General Hospital and A MNJ)
1 5 Aspects of Anorexia Nervosa
8- 10 P.M. —Hackensack Hospital
( NJ Psychoanalytic Society and AMNJ)
19 Principles of Child Psychotherapy
8:30- 1 0:30 P.M. — Office of Dr. Deutsch,
301 Broad St., Englewood
( NJ Psychoanalytic Society and A MNJ)
21 Tardive Dyskinesia and Other Movement
Disorders
9 A M.- 4:45 P.M —Carrier Foundation,
Belle Mead
( Carrier Foundation and A MNJ)
20 Acid-Based Electrolyte Abnormalities
Associated with Drugs
I I A M.- 12 noon — Greystone Park
Psychiatric Hospital
(AMNJ)
Apr.
2 Identify Disorder Versus Borderline
Personality
8:15-10:30 P.M. — 5 Fairfield St.,
Montclair
(Essex Psychiatric Seminar and A MNJ)
3 Strokes C'.V.A. — Post and Rehabilitation
Care
1 1 A.M - 12 noon — Greystone Park
Psychiatric Hospital
( Greystone Park Psychiatric Hospital and
AMNJ)
5 Behavior Medicine and Biofeedback
12 Treatment Issues of the Depressed
Woman
19 Cross-Cultural Psychiatry
12 noon-1 P M.— Carrier Foundation,
Belle Mead
(Carrier Foundation and A MNJ)
6 Psychiatric Lecture Series
13 1:30-5 P M — Trenton Psychiatric
Hospital
27 (Trenton Psychiatric Hospital and
AMNJ )
9 Developmental-Behavioral Disorders:
10 Update 1984
11 Glenpointe Hotel, Teaneck
12 (Hackensack Medical Center and
13 AMNJ)
1 1 The Sleepless Patient
9:15 A M.- 4:30 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and A M NJ)
11 Update in Psychosomatic Medicine
2-5 P.M., 7-9 P.M. —Stony Hill Inn,
Hackensack
( North Jersey Psychiatric Society and
A MNJ)
16 Principles of Child Psychotherapy
8:30-10:30 P.M. — 301 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and A M NJ)
18 Group Therapy
25 2-3 P.M.— Ancora Psychiatric Hospital,
Hammonton
( Ancora Psychiatric Hospital and AMNJ)
19 Controversies and Pitfalls in Modern Sex
Therapy
5-6:30 P.M. — Somerset Medical Center,
Somerville
(Somerset Medical Center and AMNJ)
OBSTETRICS/GYNECOLOGY
Mar.
9 Semmelweis-Waters Ob/Gyn Conference
10 8 A.M. -5 P M. — Resorts International
11 Hotel, Atlantic City
(UMDNJ — NJ Medical School, Dept, of
Ob/ Gyn and Office of Continuing
Education and A M NJ)
31 Contraception Today
9 A.M. -5 P.M. —Princeton Scanticon
Conference Ctr., Princeton
(UMDNJ-Rutgers Medical School and
A MNJ)
Apr.
1 Contraception Today; Improving the
Results, Reducing the Concerns
9 A.M -12 noon — Princeton Scanticon
Conference Ctr., Princeton
( UMDNJ-Rutgers Medical School and
A MNJ)
PATHOLOGY
Mar.
1 Biology of Immune Complexes in Cancer
8 Epidemiology of Cancer: An Overview
4-6 P.M. — Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
A MNJ)
14 Pathology Grand Rounds
10:30 A.M. -12 noon — St. Mary's
Hospital, Passaic
(St. Mary 's Hospital and A M NJ)
21 Pathology Slide Seminar/New Procedure
Update
7-9 P M— Hyatt House, Cherry Hill
( South Jersey Pathology Society and
A MNJ)
Apr.
11 Pathology Grand Rounds
10:30 A.M. -12 noon — St. Mary's
Hospital, Passaic
(St. Mary's Hospital and A M NJ )
12 Radio-labeled Antibodies for Cancer
Detection and Therapy
4-6 P M.— Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
PEDIATRICS
Mar.
1 The Mouth and Teeth in Pediatric
Practice
9 A.M. —Freehold Area Hospital
(AMNJ)
19 Pediatric Lecture Series
12 noon-1 P.M. —The Mountainside
Hospital, Montclair
( The Mountainside Hospital and A M NJ )
21 Chronic Disorders in Pediatrics:
22 New Approaches to Old Problems
8 A.M. -4 P.M. —Madison Hotel, Convent
Station
(Children's Specialized Hospital)
VOL. 81— NUMBER 2— FEBRUARY 1984
151
23 Diagnosis and Management of the
V arious Forms of Rickets
8-9:30 A.M. —Overlook Hospital,
Summit
(Overlook Hospital and A M NJ)
Apr.
5 Hematonia and Proteinura in Children
9 A. M.— Freehold Area Hospital
(A MNJ)
16 Pediatric Lecture Series
12 noon-1 P.M. — Mountainside Hospital,
Montclair
( Mountainside Hospital and A M NJ)
25 Pediatric Allergy
10:30 A.M. -12 noon — St. Mary’s
Hosptial, Passaic
(St. Mary 's Hospital and A M NJ)
RADIOLOGY
Mar.
8 New Aspects of Obstetrical and
Gynecological Ultrasound
8:30-9:30 A. M. — Saint Barnabas Medical
Ctr., Livingston
(New Jersey Institute of Ultrasound in
Medicine and A MNJ)
16 Radiology Meeting
7:30-10 P.M. —Saint Barnabas Medical
Center, Livingston
( Radiological Society of NJ and
Radiological Section, A M NJ)
21 Dinner Meeting
6:30 P M.— The Manor, West Orange
(Radiotherapy Section, A MNJ)
Apr.
12 Invasive Fetal Therapy
8:30-9:30 P.M. —Saint Barnabas Medical
Ctr.
(New Jersey Institute of Ultrasound in
Medicine and A MNJ)
18 Pathogenesis, Diagnosis, and
Management of Type II Diabetes
1-2:30 P.M. — VA Medical Center, Lyons
( VA Medical Center and A MNJ)
19 Radiology Meeting
7:30-10 P.M. —Saint Barnabas Medical
Ctr., Livingston
I Radiological Society of NJ and
Diagnostic Radiology Section, AM NJ)
26 Radiation Therapy: Current Practice and
Future Potential
4-6 P.M. —Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
A MNJ)
SURGERY
Mar.
4 Use of Appropriate Antibiotics in Surger
10:30 A.M. -12 noon — St. Mary’s
Hospital, Passaic
(St. Mary's Hospital and A M NJ )
7 Diagnosis and Surgical Management of
Esophageal Reflux and Fliatus Hernia
10:30 A.M. -12 noon — St. Mary’s
Hospital, Passaic
(St. M ary 's H ospital and A M NJ)
7 Surgical Departmental Conference
14 8:30-10 A M — Rutgers Medical School,;
21 New Brunswick
28 ( UM DNJ-Rutgers Medical School)
Apr.
4 In and Out Surgery
10:30 A.M. -12 noon — St. Mary's
Hospital, Passaic
(AM NJ)
4 Surgical Departmental Conferences
1 1 8:30-10 A. M.— Rutgers Medical School,
18 New Brunswick
25 ( UM DNJ — Rutgers Medical School and
A MNJ)
SURGICAL SPECIALTIES
Mar.
1 Vascular Surgical Rounds
8 4-5 P.M. — Rutgers Medical School,
15 New Brunswick
22 ( UM DNJ-Rutgers Medical School)
29
6 Surgical Management of Benign and
Malignant Disease of the Breast
7:30 P.M —Burdette Tomlin Memorial
Hospital, Cape May Court House
(A MNJ)
31 Management of Patients with Low Vision
8: 1 5 A.M.-4:30 P M —Saint Barnabas
Medical Center, Livingston
(St. Barnabas Medical Center and
A MNJ)
Apr.
5 Vascular Surgical Rounds
12 4-5 P.M. —Rutgers Medical School,
19 New Brunswick
26 t UM DNJ-Rutgers Medical School and
A MNJ)
7 9th Annua! Orthopaedic Symposium
8A.M. — UMDNJ-Rutgers Medical
School, Newark
(AMNJ)
1 1 Yag Laser Use in Ophthalmology
I -2:30 P.M. —Christ Hospital, Jersey City
(Christ Hospital and A M NJ )
18 Biliary Tract Surgery
10:30 A.M. -12 noon — St. Mary’s
Hospital, Passaic
(St. Mary 's Hospital and A M NJ)
26 Glaucoma: A Compendium of Diseases
8-10 P.M — Bergen County Medical
Society, Hackensack
(NJ Medical Women's Association and
A MNJ)
MISCELLANEOUS
Mar.
Clinicolegal Correspondence Course
Self-Instruction-Contact Medical Inter-
Insurance Exchange of New Jersey
( Medical Inter-Insurance Exchange of NJ
and A MNJ)
218th Annual Meeting
May 2-6, 1984
Wednesday, May 2, 1984
3:30 p.m. — Board of Trustees' Meeting
7:00 p.m. — Officers' Cocktail Reception followed by Dinner
Thursday, May 3, 1984
9:00 a.m. — Registration Opens
2:00 p.m. — House of Delegates
4:00 p.m. — Reference Committees (Three Reference Committee
Meetings)
Friday, May 4, 1984
7:30 a.m. — Registration Opens
9:00 a.m. — House of Delegates (election)
9:00 a.m.— Message Center, and Scientific, Informational, and Insurance
Exhibits Open
I 2:00 noon — Golden Merit Award Ceremony followed by Reception
2:30 p.m. — Reference Committees (Three Reference Committee
Meetings)
5:00 p.m. — JEMPAC Political Forum
5:45 p.m. — JEMPAC Wine & Cheese Reception
Saturday, May 5, 1984
8:00 a.m. — Registration Opens
9:00 a.m. — Message Center, and Scientific, Informational, and Insurance
Exhibits Open
9:00 a.m. — Scientific Sessions
12:00 noon — Luncheons
1 :00 p.m. — Scientific Sessions
6.30 p.m. Inaugural Reception followed by Inaugural Dinner
Sunday, May 6, 1984
6:30 a.m. — County Society Breakfast Caucuses
8:00 a.m. — Registration Opens
9.00 a.m. Message Center, and Scientific, Informational, and Insurance
Exhibits Open
9:00 a.m. — House of Delegates
3:00 p.m.— Board of Trustees' Meeting
152
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ETTER TO THE EDITOR
(
Alternative Treatment
o Breast Cancer
November 30, 1983
)ear Doctor Krosnick:
Dr. Greco’s recent commentary on
le treatment of breast cancer (Novem-
er 1983) should serve to stimulate not
nly surgeons, but all physicians, to re-
valuate their own entrenched views
oncerning the conventional manage-
lent of breast cancer.
The growing body of scientific
vidence from centers in France, Italy,
Canada, and the United States, suggests
hat conservative surgery combined with
adiolherapy is an acceptable alternative
to mastectomy for those patients having
a strong motivation for breast preser-
vation. A good summary of such data
is found in a newly published text.'
Meaningful randomized prospective
studies are difficult to obtain in an ill-
ness so charged with emotional feelings.
A bias is introduced at the onset of such
studies since only a small percentage of
women with breast cancer will allow
themselves to be randomized.
While there are well-known advan-
tages and disadvantages to both conven-
tional and conservative therapy, one
cannot help but wonder if women would
come forth sooner with earlier, more
curable breast cancers if they did not
always believe that a mastectomy was
mandatory. Any disadvantage of con-
servative treatment for breast cancer
might be offset by the availability of
such therapy serving as a stimulus to
women to seek earlier treatment,
hopefully resulting in a greater number
of cures.
For the present, it certainly would
seem prudent to keep an open mind to
both forms of therapy and to inform
patients fully of their alternatives.
Murray H. Seltzer, M.D.
REFERENCE
1. Harris JR, et al. : Conservative Manage-
ment oj Breast Cancer. Philadelphia, PA, J.B.
Lippincott Co., 1983.
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the "con-
spiracy of silence" that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle" on a suffering colleague is indeed an ACT OF LOVE!
Cal! Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
VOL. 81— NUMBER 2— FEBRUARY 1984
153
OBITUARIES
—
Dr. Sidney L. Cohen
Word has been received of the death
of Sidney L. Cohen, M.D., an emeritus
member of our Essex County compo-
nent. Born in 1899, Dr. Cohen earned
his medical degree from New York
Medical College in 1925. A family prac-
titioner, Dr. Cohen was affiliated with
Newark Beth Israel Medical Center.
Dr. Paui B. Ferrary
At the age of 74, Paul Bernard Fer-
rary, M.D., died on November 8, 1983.
Dr. Ferrary received his medical degree
from Georgetown University School of
Medicine, Washington, D.C., in 1933. A
member of our Passaic County compo-
nent and of the American Medical As-
sociation, Dr. Ferrary was affiliated
with St. Joseph Hospital and Medical
Center, Paterson. A diabetologist, Dr.
Ferrary practiced in Totowa during his
lengthy career.
Dr. Perry 0. Hall
At the grand age of 88, Perry O. Hall,
M.D., died on November 17, 1983. Dr.
Hall was a graduate of the University of
Pennsylvania School of Medicine in
1920. An obstetrician-gynecologist, Dr.
Hall was affiliated with Margaret Hague
Maternity Hospital, Jersey City, West
Hudson Hospital, Kearny, Elizabeth
General Medical Center, and Jersey City
Medical Center. In 1970, Dr. Hall was
a recipient of MSNJ’s Golden Merit
Award for 50 years of medical service.
He retired from practice in 1973. Dr.
Hall was a retired member of our
Hudson County component and a mem-
ber of the American Medical Associa-
tion.
Dr. Harold E. James
We have learned of the death of
Harold E. James, M.D., a member of
our Essex County component. Born in
1918, Dr. James received his medill
degree from New York Medical Coll i
in 1961. A surgeon, Dr. James was
filiated with three Newark hospit;!
Saint James Hospital, St. Michac
Medical Center, and Presbyterian H
pital.
Dr. Sol S. Winsten
Sol Stephen Winsten, M.D., a me
ber of our Essex County compone5
died on November 16, 1983. Born
1909, Dr. Winsten earned his medi(
degree at the University of Berne, Swi
erland, in 1939. A psychiatrist, E
Winsten was affiliated with Muhlenbe
Hospital, Plainfield, St. Michael's Me<
cal Center, Newark, and John E. Ru
nells Hospital of Union Coum
Berkeley Heights. Dr. Winsten was
member of the American Medical A
sociation and a Diplomate of the Ame
can Board of Psychiatry and Neurolog
154
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
BOOK REVIEWS
i |
s
Zo\or Atlas of Life
Before Birth
Marjorie A. England. Chicago, 1L, Year-
book Medical Publishers, 1983. Pp. 216.
This book actually represents an atlas
)f embryology which is a welcome aid
o the medical student as well as to the
specialist preparing for his boards. The
ohysical aspect of the book is outstand-
ng; the binding is sturdy, the paper is
flossy and of good quality, the print is
clear and easy to read, and the color
reproductions are superb. The author is
an anatomist at the distinguished Uni-
versity of Leicester, England, and should
be congratulated for the completion of
his most instructive book which deals
With a difficult subject.
The contents deal with the develop-
nent of the fetus from the moment of
Conception until birth and the book is
profusely illustrated. The pictures are
well marked with numbers which ex-
olain the names of the developing or-
gans. New are the illustrations of fetal
(ultrasonograms as well as the x-ray pic-
tures in utero. Each organ is not only
depicted macroscopically but the normal
histology of each organ is included.
The illustrations of the placenta and
the fetal membranes are likewise re-
markable and afford an excellent insight
ias to the happenings before birth.
It should be emphasized that this
book represents only the normal em-
bryology; therefore abnormal develop-
ments, such as failure of closure of due-
tus arteriosus, or failure of fusions of the
Mullerian ducts, or anencephaly, are not
depicted; for those the student should
refer to the usual textbooks of em-
bryology, e.g. Arey.
The book should be extremely valu-
able to obstetricians, internists, and
urologists, and, last but not least, to for-
ensic physicians since it will give an
exact picture of the fetus during each
month of development. The book is
highly recommended.
Werner Steinberg, M.D.
Coronary Artery Disease in
Infants and Children
Henry N. Neufeld, M.D., and Adam
Schneeweiss, M.D. Philadelphia, PA,
Lea & Febiger, 1983. Pp. 189.
The foreword states, “A new outlook
on coronary diseases in adults postulates
that the disease may have its origins in
infancy and childhood; therefore, it is
important that physicians have a clear
understanding of disease in children.” It
is in the meeting of this objective that
the book fails. The authors, however,
have succeeded in putting together in
readable form most of the known infor-
mation about congenital anomalies of
the coronary arteries. A lesser amount
of information regarding acquired dis-
eases of the coronary arteries also is in-
cluded. No new ground is broken here,
but such a review of the literature is
valuable.
Since the title of the book implies a
discussion of coronary artery disease in
childhood, it is regrettable that the
authors have elected to omit a discussion
of the current controversies regarding
diet in childhood and its implications for
the future development of arterioscler-
osis. Such a discussion would have
added greatly to the usefulness of an
otherwise fine book.
The range of interest for the book will
be quite limited, mainly due to its con-
centration on anatomic variations of the
coronary system. However, it will
provide a valuable resource to pediatric
cardiologists, pediatric and adult
cardiovascular surgeons, and a few
interested adult cardiologists.
Jay Eldredge, M.D.
Deborah Heart and Lung Center
Current Emergency
Diagnosis and Treatment
John Mills, Mary T. Ho, Donald D.
Trunkey. Los Altos, CA, Lange Medical
Publications, 1983. Pp. 738. ($24)
This 738-page book is the finest text
and reference book concerning emer-
gency medicine that I have read in the
many years that I have been involved in
emergency medicine. It covers every
medical emergency that physicians,
whether in or out of the hospital emer-
gency department, may come up against.
Every chapter includes a narrative
portion, and every subject is covered
with tables, diagrams, and radiograms
illustrating the emergency where appli-
cable. Every page in the book is utilized
including the covers: the inside front
cover lists drugs commonly used in-
travenously in emergencies, and the
back cover shows the composition of
commonly used intravenous solutions.
The book deals with medical emer-
gencies, and includes the design, oper-
ation, and staffing of the hospital emer-
gency department, the management of
mass casualties, and emergency care and
the law. In addition, there is a special
illuminating chapter on emergency
procedures.
This book should be in every hospital
emergency department and used as a
text in the hospital or reference at home
by the physician.
Jack R. Karel, M.D.
VOL. 81— NUMBER 2— FEBRUARY 1984
1 55
Primary Prevention of
Coronary Heart Disease: A
Practical Guide for the
Clinician
Richard N. Podell, M.D., and Michael
M. Stewart, M.D., (eds). Menlo Park,
CA, Addison- Wesley Publishing Com-
pany, 1983. Pp. 340.
Primary Prevention of Coronary Heart
Disease is a guide designed for the physi-
cian, in focusing on the traditional
cardiac risk factors: smoking, hyper-
tension, hyperlipidemia, diabetes
mellitus, obesity, Type A behavior, and
lack of exercise.
Each chapter starts with a brief over-
view for the reader to establish summary
thoughts on the specific risk factor and
then proceeds with a clear and under-
standable review of the current scientific
issues around the risk factor, ending
with advice to be given the patient on
primary prevention.
The subjects discussed have annotated
bibliographies, figures, charts, tables,
and appendices. Also, given in each
chapter are names and addresses of free
sources of health-care information and
patient educational materials pertinent
to coronary heart disease.
This guide can find some use in the
hands of health-care personnel as a sup-
plement to other standard textbooks on
heart disease.
Harry M. Poppick, M.D.
The Youngest Science
Lewis Thomas, M.D. New York, NY,
Viking Press, 1983. ($14.75)
Thomas is an academician, scientist,
researcher, and chancellor, but primarily
a physician who understands medicine
and its ways. Although the format of
this book is autobiographical, it serves
as an overview of medical practice in the
20th century — when medicine was
changing from an art to a science.
Thomas went to Princeton and Harvard,
but his observations parallel that of any
other medical student in the 1930s,
1940s, and 1950s.
Thomas speaks of touching as being
the most effective act of physicians
(“The doctor's oldest skill in trade was
to place his hands on the patient.”), and
decries the mechanizations and aloof-
ness of modern practice (“Medicine is
no longer the laying on of hands, it is
more like the reading of signals from
machines.”). He stresses that the new
technologies leave little time for talking
with patients and states that often their
longest and most personal conversations
are “discussions of finances and in-
surance, engaged in by personnel trained
in accountancy, whose scientific instru-
ments are the computers.” He calls for
the preservation of the uniquely subtle,
personal relationship between doctor
and patient: “To do it right has never
been easy; it takes the best of doctors,
the best of friends.”
Thomas picks neurology as the most
fascinating of all fields of medicine, and
his chapter on that subject explains why.
It was his early interest in this field that
made him the superb scientist he is;
would that every physician had his
enthusiasm for research! He feels “the
key to a long, contented life in the lab-
oratory is to have a chronic insoluble
problem and keep working at it.” His
comparison of the human mind with
artificial intelligence (the computer) is
fascinating — he admires the latter, but
respects the former and acknowledges
that he does not understand it: “My own
mind, fallible, error-prone, forgetful, un-
predictable, and ungovernable, is way
over my head.”
Thomas traces his rise up the lad' i
of academic success — from a naval ul
of the Rockefeller Institute Hospital]
Guam and Okinawa in 1942, to the f'4
tional Institutes of Health in BetheS' ,
to Johns Hopkins (pediatrics), to Tub ;
(microbiology and immunology), to 3
University of Minnesota (pediatrics al
medicine), to New York University C •
lege of Medicine (pathology), J
Bellevue (medicine), to being a memli
of the New York City Board of Heal
He took a sabbatical leave at the Univ :
sity of Cambridge to work on 1
placenta. He became the dean of tr
medical schools (New York Universi
and Yale), and finally reached his pi nr *
cle as chancellor of the Memorial Slot
Kettering Cancer Center.
He is a skillful writer. In the chapt
“Illness,” he describes vividly how d
ficult it is for a doctor to be a patiei
His glimpses into his inner self (1
colon, his mesenteric vessels, and 1
knee joint) are vivid and told with
subtle sense of humor. Thomas co
eludes that his existence is not in t
midst of his bodily parts, but perha
“an assemblage of electromagnetic pz
tides” beyond his management, runnii
itself.
The appendix is full of “some i ter
of verse” which added to his incon:
during internship and residency. T1
tirst stanza of “Millennium” should l
enough to stimulate you to read the re
of the poem, and, in fact, the who
book, which I am sure will become
classic: “It will be soft, the sound th;
we will hear/ When we have reached til
end of time and light./ A quiet, fin;
noise within the air/ Before we are re
turned into the night.”
John S. Madara, M.E!
156
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
NFQRMATPN FOR AUTHORS
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70L. 81— NUMBER 2— FEBRUARY 1984
157
CLASSIFIED ADVERTISEMENTS
ANESTHESIOLOGIST— Board certified,
experienced anesthesiologist seeks position in
Central or South Jersey. Broad clinical ex-
perience in all phases of Anesthesiology.
Small hospital preferred. Resume and details
on request. Reply to Mainland Anesthesia
P.A., 52 East New York Avenue, Somers
Point, NJ 08244. Call (609) 927-7782.
GASTROENTEROLOGIST-University
trained. Trained in all procedures including
ERCP, laparoscopy, sclerotherapy. Seeks
practice opportunities in New Jersey begin-
ning July 1984. Contact Dr. H.L.
Kirschebaum, 780 Woolley Avenue, Staten
Island, NY 10314.
GENERAL PRACTITIONER— Desires in-
dustrial, pharmaceutical or similar position.
Semi-retired, age 55, (201) 545-4339.
GENERAL SURGEON— Board certified,
wishes to join another surgeon or a group in
area of Monmouth County or adjoining
counties. If interested please contact Dr.
Hasan (201) 972-1584.
INTERNIST — Board eligible, looking for an
opportunity to join group practice in North
or Central New Jersey starting July 1984.
Please call (201) 533-1982 or contact Dr.
Bardmesser, 145 Sycamore Avenue, Liv-
ingston, NJ 07039.
OB/GYN — Board certified, 35, experienced.
Wants to relocate. Solo, group or partner-
ship. Available immediately. Write Box No.
66, JMSNJ.
OPHTHALMOLOGIST — Board eligible, July
1984, Board certified Pediatrics (1982), age
29, desires partnership or group. Available
July 1984. Write Box No. 65, JMSNJ.
PHYSICIAN — Semi-retired, age 57, seeking
part time or full time position. Preferable in-
dustrial clinic. Telephone (201) 224-5252.
NEEDED ASSOCIATE — Pediatrician,
board certified; seeks associate, board certi-
fied/eligible, to join well established practice.
Excellent opportunity. Northern New Jersey
near New York City. Write Box No. 40,
JMSNJ.
DIAGNOSTIC RADIOLOGIST— Board
certified, trained in general diagnosis, nuclear
medicine, special procedures, C.T. and ultra-
sound. Available full or part-time; group
practice or hospital based; North or Central
New Jersey. Can also provide mobile ultra-
sound and office consultation. Reply to Box
No. 63, JMSNJ.
NEEDED INTERNIST— Board certified/
board eligible. Must have had training in
cardiology, gastroenterology and endoscopy
for Associate position in busy general prac-
tice Northern New Jersey suburban setting.
Submit resume to Box No. 56, JMSNJ.
NEEDED OB/GYN — To join solo practice in
South Jersey Shore area. Growing area. One
hour from Philadelphia. Write Box No. 42,
JMSNJ.
NEEDED PHYSICIANS— Family Practice in
Central Jersey needs doctor with malpractice
insurance to work occasional Saturdays and
weekdays or week nights. (201) 722-2522.
NEEDED PHYSICIANS— New Free Stand-
ing Emergency Clinic in Central Jersey needs
Medical Director plus full and part-time
physicians. Write P.O. Box 6485,
Bridgewater, NJ 08807.
INTERNAL MEDICINE-Board eligible,
general internist with extensive emergency
room experience seeking group practice of
internal medicine or emergency room pos-
ition. Northern New Jersey area. Available
July 1984. Please call (212) 645-4616. Steven
Wolinsky, M.D. Curriculum vitae and refer-
ences available upon request.
NEEDED PRIMARY CARE PHYSICIANS
— Private fee-for-service practice in new, fully
equipped suburban offices. All personnel sup-
plies, and management services provided.
This is an excellent opportunity for phys-
icians with a good “bedside” manner
interested in developing a lucrative practice
and still desiring time for the pursuit of hap-
piness. Reply to: Neighborhood Doctor Cor-
poration, 901 Long Beach Blvd., Ship Bot-
tom, NJ 08008.
NEEDED RADSOLOGIST-Part time, 2
mornings per week. Ocean County. Prefer
competent retired person. Write Box No. 62,
JMSNJ.
ALLERGY PRACTICE — Allergist certified
or board eligible for Purchase of very de-
sirable Practice, child and adult. Central NJ.
Write Box No. 47, JMSNJ.
PRACTICE FOR SALE— ENT, established
16 years. Fully equipped modern office. Ex-
cellent location. Terms available. Deceased-
immediate. Vineland, NJ. Close to Atlantic
City and Philadelphia. (609) 692-2536.
PRACTICE FOR SALE— OB/GYN. Im-
mediately in Northern Monmouth County,
near two accredited hospitals in appealing
residential community. Will introduce. (201)
264-7763.
PRACTICE FOR SALE-Pediatrics. L(ji
established practice, V2 block from hospi . «
Property and equipment. Located in Midc-
sex County. Will introduce. Write Box FJ
64, JMSNJ.
PRACTICE FOR SALE OR RENT— Farr
Practice, for sale or rent office and equipimi
near a 550 bed teaching hospital in Milil
mouth County. Call after 6 P.M. (2tJ
681-2566.
-
FOR SALE OR RENT— Fully equipped a
furnished medical office building includi
small medical practice, ECG, x-ray machin/ ’
therapeutic ultrasound, Pulmonor. Good 1 ff
cation. Kearny. Call after 8 P.M. (2C r
746-1709.
FOR SALE— OFFICE SPACE. Rosel
modern 2,400 square feet, 6 treatment roor
and 4 consultation rooms. On-site parkin
Warinanco Medical Building. Phone (20
687-0102.
OFFICE SPACE SHARE NEEDED— Boa
certified internist desires office spaces
Camden County (Cherry Hill, Haddonfie
area) or Salem County area. Call Dr. Chi
(513) 475-4368.
OFFICE FOR SHARE — Highland Park, 9(
square feet office space, fully equipped. Ne;
hospital, minimal rent. $250.00 per mont
including utility and equipment. For detai
call (201) 545-2045.
OFFICE SPACE TO SHARE— Morristowi
central location. Near hospital, full
equipped, newly decorated. All utilities it
eluded. Ample parking available. Near publ
transportation. Available immediately. (20
267-2555.
SHARE OFFICE — Ridgewood, near Valle
Hospital, Prime medical space, new building
large parking lot, easily accessible on mail
road. Call (201) 652-6060.
OFFICE SPACE TO SHARE— Westfield
central location. Near hospital, full;
equipped, attractively decorated. All utilitie
included. Ample parking available. Near pub
lie transportation. Available immediately
(201) 267-2555.
OFFICE FOR RENT — Bergen Count)
Ridgefield, NJ. Office for rent, 700 squar
feet. Call (201) 833-01 17.
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COPY DEADLINE: Fifth of preceding month.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
158
CLASSIFIED ADVERTISEMENTS
i'FICE SPACE — For immediate occupancy
iivv, modern, energy efficient rental 500 to
KtOO square feet available from $5 per foot.
!,000 residents within three mile radius,
use to Philadelphia, Atlantic City in Cen-
1 Jersey shore area. Internists and special-
les needed. Ideal for main/satellite office.
11 (201) 350-1008.
OFFICE SPACE — Southern NJ, Gloucester
Township, Camden County. Office suite in
new medical building for rent; 1000 or 2000
square foot suites available. Located in rapid-
ly growing, highly desirable area, near several
large hospitals. Ideal for family practice or
specialist. Building to be completed late 1984.
Call Dr. Ribatsky (609) 227-2221.
OFFICE SPACE — North Haledon. Two side
by side 750 square feet suites available in
professional building close to Paterson Gen-
eral Hospital. Immediate occupancy. Will
alter to suit or Purchase the entire 3000
square foot building. Free basement storage.
Call (201) 427-7500.
I TICE SPACE— Ed ison, 1 ,2 1 4 square feet,
l oom, bathroom, carpeted, near all high-
■ ys and hospitals, on-site parking. Avail-
Re immediately. Call Dr. Bronstein (201)
1-8000.
>:FICE FOR RENT — Edison, 1,300 square
fij'-t, new building, 172 Amboy Avenue.
Inple parking, no steps. Near Perth Amboy
Id JFK hospitals. Call (201) 442-4444.
|
OFFICE FOR RENT OR SHARE — Hazlet,
Holmdel area, 600 to 1500 square feet,
furnished, ample parking. Close to hospital.
Call (201) 264-7763.
OFFICE SPACE — Moorestown, NJ. Vic-
toria Medical Arts Building. Renting custom
medical offices in new building. Ideal for
radiologist, orthopedist, urologist, general
surgeon, industrial physician. Excellent lo-
cation and parking. Call (609) 235-2651.
OFFICE FOR RENT — Professional office for
rent, approximately 710 square feet near
Dover General Hospital. Near Routes 80 and
46. Morris County, NJ. Telephone (201)
366-2557.
FOR SALE — Boat. 1982 Sea Ray Sedan 26
foot, all extras. Call (201) 864-7172.
RATE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance. WORD
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DOPY DEADLINE: Fifth of preceding month.
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
I or the Investigation of
Problems of Human Infertility
'The Foundation provides a complete
[diagnostic and consultation service for in-
fertile couples. Investigations are con-
ducted by well-known specialists in con-
junction with consultants in the various
fields of medicine related to infertility.
tThe Foundation is supported by an in-
jhouse modern laboratory equipped to do
most tests required for diagnosis and
-Treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
Personnel
See Page 160
OFFICE SUITE
Millburn Ave., Maplewood-small prof. bldg. 1
suite avail. Approx. 1000 sq. ft. $1,200.00
mth.— set for M.D., etc. 3 trmt. rms., sml. kitchen,
x-ray r m . , lav., waiting rm., Nurse station &
storage— 1st fir.
Call L.L. Leifer, Esq., Days (201) 763-8555, Eve.
(201) 325-8630.
OL. 81— NUMBER 2— FEBRUARY 1984
159
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• Provides the qualified physician with the opportunities to become a member of global health care system.
• Is practiced in excellent medical facilities in conjunction with a highly professional staff of support
personnel.
• Allows the physician the advantage of experiencing all aspects of medicine including teaching, research,
administration and graduate medical education without the associated career disruption.
• Provides the physician with an officer’s commission with attendant benefits and privileges.
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OUTSIDE NEW JERSEY CALL COLLECT - (201) 227-1800
VOL. 81— NUMBER 3— MARCH 1984
161
March 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 766
Officers and Trustees
President
Alexander D. Kovaes. M.D. (Union) Scotch Plains
President-elect
Frank Y. Watson. M.D. (Essex) Glen Ridge
First Vice-President
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
Second Vice-President
Edward A. Schauer, M.D. (Monmouth) Farmingdale
Immediate Past-President
Howard D. Slobodlen. M.D. (Middlesex) Metuchen
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch. M.D. (Somerset) Bridgewater
Trustees
Douglas M. Costabile, M.D.,
Chairman (1984) (Union) Murray Hill
Frank Campo, M.D. (1984) (Mercer) Trenton
Harry M. Carnes, M.D. (1985) (Camden) Audubon
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
John J. Crosby, Jr., M.D. (1984) Jersey City
Palma E. Formica, M.D. (1984)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr.. M.D. (1985)
(Salem) Carney's Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
William Greifinger, M.D. (1984) (Essex) Belleville
John P. Kengeter, M.D. (1984) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Michael R Ramundo, M.D. (1984) (Passaic) Clifton
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1984) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A. Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Albert F. Moriconi, M.D. (1985) Trenton
Fourth District
(Burlington. Camden. Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1984) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. DElia, M.D., Chairman (1985) Spring Lake
Allred A. Alessi, M.D. (1984) Hackensack
Frederick W. Durham, M.D. (1984) Haddonfield
1 alma E. Formica, M.D. (1984) New Brunswick
Karl T. Franzoni, M.D. (1984) Trenton
John S. Madara, M.D (1984) Salem
Henry J. Mineur, M.D, (1984) Cranford
Myles C. Morrison, Jr., M.D (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd. M.D. (Ridgewood)
Publication Committee
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Wm. A Dwyer, Jr„ M.D. (Surg)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield. M.D. (Cardiol)
Benjamin F. Rush, Jr.. M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal ol the Medical Society ot New Jersey (ISSN-0025-7524) is published monthly (since 1904) except
semimonthly in July ( 13 issues), under direction of the Committee on Publication, by the Medical Society of New
i° rJ hccss Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA, by the Hughes Printing
Ca whole numbe issues 960. Member’s subscription ($10) is included in Society dues. Rates for nonmembers,
D . ’ outslcle USA : yr postage. Single copies, $2. Address communications to The Journal MSNJ, Two
rinc ess Road, Lawi >j >. y (609) 896-1766. Second-class postage paid at Trenton, NJ, and additional
entry office. Copyngh the Medical Society of New Jersey.
162
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
essmen don't set
dards. Doctors do
Howard Slobodien, M.D., General Surgeon, Perth Amboy-Edison, NJ
Immediate PaslPresident. Medical Society of^New Jersey
“Before I joined my local IPA
(Individual Practice Associa-
tion), which is a participant in
Health Ways, I needed some
basic questions answered.
Question 1: With cost con-
tainment so critical to the
HealthWays' philosophy, will I
have to follow guidelines set up
by an accountant?
Answer: No. All the medical
checks and balances in Health-
Ways are checked and balanced
by doctors. Colleagues all. Their
guidelines are far from arbitra-
ry. They not only make for good
medicine, they make good sense.
Question 2: Can I maintain
the high quality of my practice
without worrying about driving
patients to the poorhouse?
Answer: With HealthWays'
unique reimbursement policy
— I can and do. They even cover
routine check-ups, and you
know their importance.
Question 3: Are there any
other practical advantages for
the physician?
Answer: Yes. Several. Since
all bills are directed to Health-
Ways, there are no bad debts
with my HealthWays patients.
There are also other benefits
which you should check out for
yourself. "
For answers to all your ques-
tions and full information, call
Jon Marsicano, M.D., Vice
President, Medical Affairs, at
201-636-6200 or 609-394-1995.
HealttiWays
THE WAY TO BETTER J HEALTH CARE
(<? 198.1 1 lealthWays Inc
VOL. 81— NUMBER 3— MARCH 1984
163
The Journal
of the Medical
Society of
New Jersey
MARCH 1984
Features —
Membership Newsletter
Professional Liability Commentary
Editorials
Hospital Governing Boards
mwa Contributions i— ir—n mimm—
1 87 Psychological Effects of Rhinoplasty
AI. Glasgold, M.D., and S.B. Horowitz, Ph.D., New Brunswick
1 90 Radionuclide Testicular Scanning
J.L. McCormack, M.D., Long Branch
1 97 Evaluation of the Suicidal Adolescent Patient Admitted to an Urban
Hospital
S. Pierog, M.D., and A Hill, Ph.D., Jersey City
205 A Method of Abdominal Wound Closure
I.D. Samson, M.D., J. Schulman, M.D., J.C. Sabo, M.D.,
W.M. Schulman, M.D., L.W. Silvers, M.D., Lakewood
2 1 1 Case Report: Aneurysm of the Descending Thoracic Aorta
S.K. Agarwal, M.D., J.I. Haft, M.D., M. Bachik, M.D., Newark
2 1 7 Case Report: Radiographic Findings in Pseudomembranous Colitis
RS. Altin, M.D., Long Branch
222 Commentary: Whatever Happened to Benign Neglect?
MA Nevins, M.D., Woodcliff Lake
229 Commentary: The Conroy Case
H. Rothberg, M.D., Princeton
Doctors’ Notebook — ■
Trustees’ Minutes: January 15, 1984
President’s Column, Alexander D. Kqvacs, M.D.
UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
MSNJ Auxiliary, Mrs. Gale Wayman
AMNJ Report, Paul J. Hirsch, M.D.
Physicians Seeking Location in New Jersey
■—MSNJ Departments . .
241 CME Calendar
247 Letters to the Editor
249 Book Reviews
25 1 Obituaries
253 Information for Authors
235
236
237
237
238
238
167
175
180
185
On The Cover: Do people who
undergo a change in appearance
change in a positive psychological
sense? Drs. Glasgold and Hor-
owitz assess the consequences of
rhinoplasty to answer this ques-
tion. The full story begins on page
187. The cover illustration is by
Glenna Deutsch.
164
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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AID SERVICE CORPORATION uses quality reagents from VENTREX LABS, INC.
VOL. 81— NUMBER 3— MARCH 1984
165
Additional information available
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166
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Membership
Newsletter
THE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 9
MEDIA TECHNIQUES SEMINAR
The Council on Public Relations and MSNJ are
aware of the necessity of enlightening our membership
with the proper procedures for dealing with the vari-
ous media.
There was considerable enthusiasm from the phy-
sicians who attended the first seminar on media tech-
niques and all their suggestions have been in-
corporated into the second seminar to make it even
better.
This is an excellent opportunity to leam how to
handle media interviews and gain exposure to the vari-
ous public relation techniques. Outstanding media
personalities will be participating in this seminar.
There will be ample opportunity for questions and
answers and role play sessions.
MSNJ will be offering its Second Media Techniques
Seminar at the Executive Offices, Two Princess Road,
Lawrenceville, on Wednesday, March 21, 1984, from
9:00 a.m. to 4:00 p m. Luncheon will be served.
The registration will be limited to the first 50 appli-
cants. There will be a fee of $30 to cover expenses and
lunch. This is a tax-deductible expense and a worth-
while experience.
MEDICAL BRIEFS
Prostate Cancer Diagnosis — A technique for
diagnosing cancer of the prostate using a needle
biopsy procedure appears to offer advantages over the
use of tissue removal via the urethra Using needle
biopsy, the needle is passed through the perineum
between the anus and the scrotum into the prostate
gland. A sample of prostatic tissue is aspirated for
microscopic examination. This is much less traumatic
than tissue extracted via the urethra There also is less
possibility of seeding cancer cells into the circulation
of the vascular system.
Prostate Surgery— Pathological changes in the
prostate gland that result in an enlargement of the
prostate, particularly in older men, frequently have
been treated by using the transurethral resection
(TUR). A new procedure developed at John Hopkins
Hospital and reported in Prostate (4:473, 1983) offers
a technique that spares the nerves of the penis. As
such, it is unlikely to cause lasting impotence. The new
procedure is performed through the lower abdomen
and the completeness with which all tumor tissue is
removed makes it likely that the new technique will
become the treatment of choice.
Joint Pain and Beta Blockers— It has been reported
in the British Medical Journal (287:1256, 1983) that
19 patients who were receiving beta blockers for heart
disease or the treatment of hypertension complained
of joint pain and swelling. The joint symptoms quickly
cleared up when the beta blockers were removed. Prac-
tolol and propranol were the drugs used. It was
suspected that the drying effect of the beta blockers
in the joint that are naturally lubricated with synovial
fluid may have been the cause. Beta blockers also have
a drying effect on other normally moist surfaces such
as the eye, nose, and mouth. Patients developing joint
pain while on beta blockers can be reassured and
treated for their discomfort.
PREFERRED PROVIDER ORGANIZATIONS*
PPOs generally are designed to accomplish objectives
that stem directly from the reasons for their establish-
ment:
• They usually are established as a response to com-
petitive pressures in the local health care market such
as an HMO or an increased number of physicians com-
peting for patients in an area. They also may be estab-
lished by employers as a means to gain some control
over health care expenses.
• The PPOs overall goal is to provide easily ac-
cessible high-quality care at lower rates, thereby at-
tracting a larger share of the patient market.
« In order to accomplish this purpose the PPO must
be able to provide cost-effective medical care while
maintaining high standards of quality and access.
There are essentially three ways in which a PPO can
work toward its objective of cost effectiveness in the
delivery of medical care. It can:
‘Reprinted with permission from A Physician's Guide to
Preferred Provider Organizations. American Medical Associa-
tion, 1983.
VOL. 81— NUMBER 3— MARCH 1984
167
1
Attendance at the Board of Trustees’ Meetings: County and Specialty
New Jersey, and Auxiliary
May 1983— December 1983
Atlantic County ■ December 18
Bergen County
July 1 7
September 18
November 20
December 18
Marc J. Crilly, M.D., President-Elect
Marc J. Crilly, M.D., President-Elect
Marc J. Crilly, M.D., President-Elect
Peter A. Beaugard, M.D.
Marc J. Crilly, M.D., President-Elect
Burlington County
December 1 8 Rodolfo C. Pascual, M.D., President-Elect
Middlesex County
May 2
June 12
July 17
September 18
Camden County
September 18
November 20
December 18
Cape May
Cumberland
November 20
Essex County
May 2
June 12
July 17
September 18
November 20
December 18
Gloucester County
November 20
December 18
Hudson County
May 12
June 12
July 17
September 18
November 20
December 18
Hunterdon County
Mercer County
June 12
July 17
September 18
November 20
Louis L. Keeler, M.D., President
S, Thomas Carter, Jr., M.D.
Ix>uis L. Keeler, M.D., President
Joseph A. Riggs, M.D.
Louis L. Keeler, M.D., President
Lindsay L. Pratt, M.D.
Ralph A. Skowron, M.D.
L. Willis Allen, M.D., Immediate Past-
President
Mr. Arthur Ellenberger, Executive
Secretaiy
Carolyn W. Watson, M.D.
Carolyn W. Watson, M.D.
L. Arne Skilbred, M.D., Past-President
Carolyn W. Watson, M.D.
Bernard Robins, M.D.
Carolyn W. Watson, M.D.
Peter Amirata Jr.. M.D., President
Carolyn W. Watson, M.D.
Bernard Robins, M.D.
Carolyn W. Watson, M.D.
John S. Owens, M.D., President
Churchill L. Blakey, M.D., Secretary
Charles L. Cunniff, M.D.
Charles L. Cunniff, M.D.
Chester R. Rydwin, M.D., President
Charles L. Cunniff, M.D.
Charles L. Cunniff, M.D.
Janet Geraghty-Deutseh, M.D.
Mrs. Adelene F. Lynch, Executive
Secretary
Frank J. Primich, M.D.
Charles L. Cunniff. M.D.
Joseph W. Fleisher, M.D.
Janet Geraghty-Deutseh, M.D.
Frank J. Primich, M.D.
Chester R. Rydwin, M.D., President
Janet Geraghty-Deutseh, M.D.
Frank J. Primich, M.D.
Chester R. Rydwin, M.D.
Mrs. Joey Huddy, Executive Secretary
Mrs. Joey Huddy, Executive Secretary
William F. Wittenbom, Jr., M.D.,
President
Mrs. Nancy Baron. Assistant Executive
Secretaiy
Michael J. Larkin, M.D.
Mrs. Joey Huddy, Executive Secretary
Michael J. Larkin, M.D.
Ms. Anne Petchel
November 20
December 18
Monmouth County
June 12
September 18
November 20
December 18
Morris County
June 12
July 17
September 18
November 20
December 18
Ocean County
November 20
December 18
Passaic County
September 18
November 20
December 18
Salem County
May 2
November 20
Somerset County
July 1 7
Sussex County —
Union County
May 2
June 12
July 17
September 18
November 20
ieties. Academy of Medicine of
Michael J. Larkin, M.D.
Mrs. Mary Alice Bruno, Executive
Director
Mrs. Mary Alice Bruno, Executive
Director
Mrs. Mary Alice Bruno. Executive
Director
Mrs. Mary Alice Bruno, Executive
Director
Mrs. Maiy Alice Bruno, Executive
Director
Jon Marsicano, M.D.
Mrs. Maiy Alice Bruno, Executive
Director
Norval F. Kemp, M.D., President-Elect
Albert J. Kolarsick, M.D., Past-President
John E. Bocker, M.D., President
Mrs. Patricia Klemm, Executive
Secretaiy
John E. Bocker, M.D., President
Mrs. Patricia Klemm, Executive
Secretary
John E. Bocker, M.D., President
Mrs. Patricia Klemm, Executive
Secretaiy
Arthur Ginsburg, M.D., President-Elect
Arthur Ginsburg, M.D., President-Elect
Allan L. Gardner, M.D., President-Elect
Arthur Ginsburg, M.D., President
James B. Massengill, M.D.
Martin L. Cohen, M.D.
Arthur Ginsburg, M.D., President
Michael C. DiBella, M.D.. President
Edward D. Fiore, M.D., President-Elect
Michael C. DiBella M.D., President
Mr. William T. McGuire. Executive
Director
Gerald H. Rozan, M.D., President
Mr. William T. McGuire, Executive
Director
Gerald H. Rozan. M.D., President
Mr. William T. McGuire, Executive
Director
Gerald H. Rozan, M.D., President
Roberta G. Rubin, M.D.
Maiy T. DiMedio, M.D.
Amante N. DeCastro, M.D., President
Stephen K. Park, M.D., President-Elect
Albert M. Doswald. M.D.. President
Frank R. Romano, M.D., Past-President
Mrs. Ethel Stevens, Executive Director
Mrs. Ethel Stevens, Executive Director
Frank R Romano, M.D., Past-President
R Gregoiy Sachs, M.D., Secretary
Frank R Romano, M.D., Past-President
Mrs. Ethel Stevens, Executive Director
Frank R Romano, M.D., Past-President
168
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Attendance at the Board of Trustees’ Meetings: County and Specialty Societies, Academy of Medicine of
New Jersey, and Auxiliary
May 1983— December 1983
(continued)
December 18
Warren County
November 20
Frank R Romano, M.D., Past-President
Mrs. Ethel Stevens, Executive Director
Volmar A. Mereschak, M.D., President
New Jersey State Society of Anesthesiologists
June 12
July 17
September 18
November 20
December 18
Stanley Bresticker, M.D.
Stanley Bresticker, M.D.
Stanley Bresticker, M.D.
Stanley Bresticker, M.D.
Stanley Bresticker, M.D.
New Jersey Dermatological Society
June 12 Frederick Haberman, D.O.
November 20 Gabriel Sciallis, M.D., President
December 1 8 Frederick Haberman, D.O.
New Jersey Chapter, American College of Emergency
Physicians
June 1 2 Rudolf E. Schwaeble, M.D.
July 1 7 Rudolf E. Schwaeble, M.D.
September 18 Rudolf E. Schwaeble, M.D.
November 20 Rudolf E. Schwaeble, M.D.
December 18 Rudolf E. Schwaeble, M.D.
New Jersey Society of Internal Medicine
May 2 Frank J. Malta, M.D., Past-President
June 12 Frank J. Malta, M.D., Past-President
July 17 Frank J. Malta, M.D., Past-President
September 18 Frank J. Malta, M.D., Past-President
November 20 Frank J. Malta, M.D., Past-President
December 18 Frank J. Malta, M.D., Past-President
New Jersey Association of Medical Specialty Societies
May 2 Frank J. Malta, M.D., Vice-President
June 12 Stanley Bresticker, M.D., President
Frank J. Malta, M.D., Vice-President
July 1 7 Stanley Bresticker, M.D., President
Frank J. Malta, M.D., Vice-President
September 1 8 Stanley Bresticker, M.D., President
Frank J. Malta, M.D., Vice-President
November 20 Stanley Bresticker, M.D., President
Frank J. Malta, M.D., Vice-President
December 18 Stanley Bresticker, M.D., President
Frank J. Malta, M.D., Vice-President
Medical Womens Association of New Jersey
September 1 8 Roberta G. Rubin, M.D.
New Jersey Neurosurgical Society
May 2 Lawrence Strenger, M.D.
Obstetrical and Gynecological Society of New Jersey
November 20 John D. Franzoni, M.D.
December 18 Courtney A. Malcamey, M.D., President
New Jersey Academy of Ophthalmology and Otolaryngology
July 17 Saul M. Tischler, M.D.
September 18 Saul M. Tischler, M.D.
New Jersey Orthopaedic Society
September 18 Edmund R. Kappy, M.D., President-Elect
New Jersey Society of Pathologists
September 1 8 William V. Harrer, M.D., President
November 20 William V. Harrer, M.D., President
December 18 William V. Harrer, M.D., President
New Jersey Society of Physical Medicine and Rehabilitation
June 12 Robert Iskowitz, M.D, Member-at- Large
July 1 7 Robert Iskowitz, M.D, Member- at- Large
September 18 Robert Iskowitz, M.D, Member-at- Large
November 20 Robert Iskowitz, M.D, Member-at- Large
American College of Physicians-New Jersey
July 1 7 Norval F. Kemp. M.D.
September 18 Norval F. Kemp, M.D.
David A Willard, M.D.
New Jersey Psychiatric Association
June 12 John C. Patterson, M.D., President
July 1 7 John C. Patterson, M.D., President
September 18 John C. Patterson, M.D., President
November 20 John C. Patterson, M.D., President
December 18 John C. Patterson, M.D., President
Radiological Society of New Jersey
September 18 Alan Herschman, M.D., President
Albert J. Salzman, M.D., Liaison
New Jersey Rheumatism Association
June 12 William E. Ryan, M.D., Liaison
July 1 7 William E. Ryan, M.D., Liaison
September 18 William E. Ryan, M.D., Liaison
November 20 William E. Ryan, M.D., Liaison
December 18 William E. Ryan, M.D., Liaison
Academy of Medicine of New Jersey
September 18
November 20
Mr. Charles J. Heitzmann, Executive
Director
Mr. Charles J. Heitzmann, Executive
Director
Sherman Garrison. M.D.
Medicial Society of New Jersey Auxiliary
June 12 Mrs. Gale Wayman, President
November 20 Mrs. Gale Wayman, President
• Select hospitals and physicians to participate who
already demonstrate a track record of providing quality
care at lower cost;
• Set up the reimbursement mechanisms to create
positive incentives for cost-conscious medical practice;
and/or
• Institute control mechanisms designed to
eliminate what the PPO considers to be unnecessary
services and/or modify imprudent behavior from
within the organization.
Early in the planning process of establishing a PPO,
decisions must be made with regard to the scope of
the organization; i.e. the number of providers to be
involved, the number of enrollees projected, the pro-
jected intensity and frequency of sendees that will be
provided, and so forth. As with the establishment of
an IPA, the size of the enrolled population to be served
and the breadth of the services to be offered will be
guided by the capacity of the organization, or the
number of providers involved. There is a trade-off to
be made in deciding on the size of the organization:
while participation by a large number of physicians in
the community may facilitate better acceptance of the
plan by both patients and physicians, participation by
a smaller number may mean that those physicians
who affiliate with the PPO will be more committed to
the successful achievement of its goals and objectives.
In addition, communication between the plan’s man-
agement and its member physicians can be more effec-
tive when fewer people are involved.
VOL. 81— NUMBER 3— MARCH 1984
169
Most PPOs are composed of both institutional and
professional providers. The methodology used to select
providers to participate in a PPO may vary with state
laws, the nature of the sponsoring or motivating entity,
and the category(ies) of costs over which the purchaser
or organizer is most eager to exert an influence. The
selection process also may not be the same for both
physicians and hospitals within a single PPO.
Two alternative physician recruitment approaches
may be considered in order to maximize the cost effec-
tiveness of the PPO:
1. Criteria can be developed by which each phy-
sician’s cost-effectiveness track record would be
measured and compared to pre-established upper and
lower limit parameters as a prerequisite for partici-
pation; or
2. All physicians can be permitted to participate in-
itially, and utilization and cost criteria can serve to
accomplish elimination of physicians who turn out not
to be cost effective within the framework of the plan.
There are advantages and disadvantages inherent in
both schemes. One advantage to the use of preselection
criteria is that by the time the participating physician
group has been selected, the organization would have
a good idea of what could be expected (especially the
first year) in terms of cost-conscious behavior; this
would have a bearing on other marketing and financial
planning issues. On the other hand, an advantage to
a more open policy might be that participation by a
larger number of physicians in the community would
facilitate better acceptance of the plan by both phy-
sicians and patients.
In some states (e.g. Virginia) the law applicable to
PPO types of arrangements is written in such a way
as to preclude insurers from establishing terms and
conditions which “discriminate unreasonably against
or among such health care providers No hospital,
physician, or other provider . . . willing to meet the
terms and conditions offered to it or him shall be
excluded." There is always considerable room for ju-
dicial interpretation regarding what constitutes “un-
reasonable" discrimination. However, it may be that
exclusion of a physician from participation in the PPO
due to consideration of that physician’s past practice
profiles might be considered unreasonable if he de-
clared himself willing to abide by the terms and con-
ditions of the contract. In states which have such
provisions, therefore, the PPO might be obliged to es-
tablish an open initial participation policy and clear
criteria for cost-effectiveness expectations.
Some PPOs have been organized to include certain
categories of providers while excluding others. Blue
Cross/Blue Shield of Minnesota’s AWARE program is
a PPO type of arrangement that applies the prudent
buyer concept only to hospitals and hospital charges.
The prudent buyer concept involves the creation of a
price or charge differential in such a way that the
patient is free to choose between a less expensive
provider option with fewer out-of-pocket costs to
himself, or a more expensive provider option that will
result in a greater out-of-pocket expense. The cost to
the insurer remains the same regardless of the option
the patient chooses. Thus, participating AWARE hospi-
tals accept the Blue Cross/Blue Shield payment as full
reimbursement for services for delivered. Non-
participating hospitals do not, and may bill the patient
for any remaining balance.
Aetna Life and Casualty’s CHOICE program at
Evanston Hospital (Evanston, Illinois) is a plan which
seeks to control costs by enlisting the participation of
a hospital and its entire medical staff and then chan-
neling all referrals for specialty and hospital care to
that institution, while allowing enrollees in the plan
to select any primary care practitioner in the com-
munity. There are no “preferred” primary practitioners
under the CHOICE plan. However, if a primary care
physician whose patient elects the CHOICE program
agrees to continue to treat his patient under the con-
ditions of the plan, he is in essence agreeing to abide
by the CHOICE plan referral procedures.
The negotiation of the fee schedule is another area
which varies greatly from one PPO to another. There
usually is, although not always, a discount involved.
Physician fees were reported in the AMA Survey of
PPOs to be discounted by 10 to 20 percent from UCR
hospitals reportedly discount their average daily
charge as much as 15 percent. Physicians’ fees may
either be stipulated in the contract (to be accepted or
rejected by the physician) or negotiated between the
provider and the PPO. More often than not, physicians’
fees are reported to be calculated using Relative Value
Scales with a different conversion factor for each phy-
sician. These conversion factors themselves are, in
some cases, the negotiable item in the participation
agreement.
Hospital payment rates are grouped and negotiated
somewhat differently than physicians’ fees. Hospital
rates may be unilaterally stipulated in the contract, or
they may be negotiated. If they are negotiated, services
most often are categorized and negotiated separately.
For example, a hospital might negotiate different dis-
count rates or prices for medical, surgical, and ob-
stetrical services, as well as for such services as alcohol
detoxification. Hospital rates have also been set at a
direct percentage discount from the average daily
charge. In some hospitals, the amount of the discount
was related to the level of volume delivered by the PPO,
i.e. the more business the PPO brought to the hospital,
the larger the discount it received. In a few cases, hos-
pitals have negotiated different prices by Diagnosis
Related Group (DRG).
The fee schedules often include one or more of a
variety of incentives to the physicians to deliver care
in the most cost-effective setting possible. For example,
some organizations have established fee schedules
such that a physician will be reimbursed 85 percent
of UCR for performing certain specified procedures in
the hospital, 100 percent of UCR for performing those
same procedures in an outpatient setting, and 110
percent of UCR for delivering those services in his own
office. Some PPOs have established lists of procedures
for which they will not reimburse inpatient care unless
the physician can demonstrate a medical justification
for hospitalization.
Some PPOs do not require that physicians and hos-
pitals offer discounts in order to participate in the
arrangement. These are often the same organizations
which utilize preselection criteria in choosing the par-
ticipating providers. The inherent assumption is that
the PPO already has selected the most efficient and
170
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
cost-effective providers in the community and that dis-
counts are therefore not necessary in order to effect
savings. Organizers who choose this methodology may
do so because they are convinced the efficiency is more
important than discounts in containing costs and they
wish to avoid providers whom they believe may hospi-
talize patients unnecessarily.
One of the characteristics that distinguishes a PPO
from some other alternative delivery and financing sys-
tems is that its providers are reimbursed on a fee-for-
service basis. Many different organizational structures
have been set up to accomplish the payment objective
efficiently. The PPO itself may be just an intermediary
organization or broker between the purchaser and the
group of providers designated as “preferred;” its func-
tions are primarily administrative and marketing.
Consequently, the PPO does not usually have a large
staff or the organizational capacity to process a great
deal of paperwork. Thus, it is not uncommon for both
the provider entity (hospital or group of physicians)
and the purchaser (insurer or employer) to perform
some of the claims review and processing functions.
The majority of the organizations surveyed by the AMA
required a claim to be submitted directly to the payor;
some required claims submission to the PPO. In either
case the providers often batch their own claims and
do medical necessity review prior to submitting them.
If the claims are submitted to the payor, payment is
usually made directly to the provider, often within two
weeks of submission. If the claim is submitted to the
PPO, the PPO may pay the providers directly and as-
sume responsibility for collection from the purchaser,
or it may pass the claim to the purchaser for payment
to the provider. Either way the timeframe for payment
is usually longer than that for claims submitted direct-
ly to the payor.
Some PPO provider participation agreements specify
a turn-around time for claims payment; some do not.
Some contracts contain a provision for interest to be
paid on claims that are not paid within the specified
timeframe. If the contract does not contain a specific
provision regarding the turnaround time for claims
payment, it is probably safe to assume that the PPO
does not plan to include speedy claims payment as a
participation incentive.
Since the patients are not usually locked-in to the
PPO arrangement and since the physicians are paid
on a fee-for-service basis, utilization review is seen by
many employers and purchasers to be the key to cost
containment for the PPO arrangement. There is con-
cern, however, that the emphasis placed by PPOs on
cost containment may lead to a decreased emphasis
on the quality of the care that is delivered. Given the
current lack of performance data it is premature to
make any definite statements regarding either the cost
effectiveness of PPOs or their effect on quality of care.
Collectively, quality assurance and utilization review
programs assess the way health services are provided,
identify medical, administrative, and fiscal deficien
cies, and implement actions to correct these deficien-
cies. Consensus has yet to be reached on a definition
of “quality care” and some even argue it defies defi
nition. General agreement does exist, however, that
quality of care can be inferred by examining the struc-
tures in place to provide care, the processes by which
care is delivered, and those measurable outcomes of
provided services which are available. The focus on
quality assurance programs is to insure that stand-
ards of medical care are maintained in practice.
Utilization review programs, in contrast, have a more
narrow focus— assuring appropriate, cost-effective
utilization of health resources (particularly hospital
and referral specialist services). Consequently, these
programs monitor member utilization patterns and
physicians’ practice patterns to identify deviations
from established norms and take actions to correct
deficiencies as appropriate.
Appropriate physician support and a suitable or-
ganizational structure are important facets of a suc-
cessful quality assurance and utilization review pro-
gram. A critical element in developing health pro-
fessional support for quality assurance and utilization
review programs is the concept of peer review. Phy-
sician input into the design and implementation of
these programs is, therefore, very important.
An essential step in the development of a credible
quality assurance program is the identification of pro-
gram goals. These goals provide a framework for pro-
gram activities and facilitate evaluation of the pro-
gram’s success. Program goals should be consistent
with the key function of the quality assurance pro-
gram, e.g. assure high quality care; identify problems
in the health services delivery system; identify and
implement corrective actions for identified problems;
and measure performance after corrective action is
taken to document change.
Program objectives should be established to docu-
ment the organization’s commitment to specific pro-
gram activities. Program objectives should be: measur-
able to permit program evaluation; realistic, thereby
fostering a sense of purposefulness among the phy-
sicians; and supported by a consenus among the phy-
sicians.
The primary focus of quality assurance program ac-
tivities should be in areas of known or suspected prob-
lems, as well as areas of general interest. The results
of quality assurance investigations and studies should
be documented and communicated to appropriate
physician panel members and physician leadership.
As with quality assurance goals, utilization review
goals should be broadly stated to: insure that medically
necessary services are provided in a cost-effective man-
ner; and limit the PPOs financial responsibility to
providing only medically necessary covered services.
Ely contrast, however, utilization review program ob-
jectives are more easily defined. These objectives
should be measurable, realistic, and medically signifi-
cant.
Types of utilization review performed by PPOs in-
clude; preadmission certification, preprocedure
authorization, concurrent review of hospital stays, sec-
ond surgical opinions, medical necessity review, level
of care review, review of hospital outpatient services,
ancillary services review, review of selected diagnoses,
review of services in physician's offices, and retro-
spective profile analysis and denials. Almost all of the
PPOs surveyed by the AMA utilize concurrent review
of hospital length of stay, and approximately half use
preadmission certification. Many organizations have
second surgical opinion programs, and most develop
VOL. 81— NUMBER 3— MARCH 1984
171
cost and utilization profiles for both physicians and
hospitals.
An important factor in the success of a utilization
review program for PPOs is the issue of who designs,
controls, and conducts the review. The AMA Survey
showed that approximately 40 percent of all reviews
are conducted by the PPO entities themselves. Con-
tracting physicians conduct almost half of all reviews;
another 20 percent are conducted by outside contrac-
tors (often private review organizations or fiscal inter-
mediaries). Among the organizations surveyed, the
PPOs review programs were almost always designed by
the PPO organizers, sometimes with input from phy-
sicians.
The utilization review system is intrinsically tied to
the reimbursement mechanism. All PPOs surveyed by
the AMA reported that medical necessity review of each
submitted claim is performed prior to rate assignment
and payment. This review is conducted by the PPO
itself prior to submission to the payor or, as often is
the case with an insurance carrier-sponsored plan, by
the purchaser prior to payment authorization.
The design of the benefits plan and coverage levels
in PPOs is usually a flexible process. The vast majority
of plans which responded to the AMA Survey allowed
employers or purchasers to select from among a variety
of benefit packages for their subscribers, or to nego-
tiate a specific package which met the special needs
of their employees. A few plans, however, have estab-
lished fixed coverage programs which they market to
area employers. In these instances the contract nego-
tiation process between the PPO and the purchaser
usually involves only the price of the contract; levels
of coverage and services to be covered are not nego-
tiable. Over 90 percent of the plans surveyed, however,
allowed the purchaser to stipulate the needs of its
population, and the benefits package and coverage
levels were then designed with those needs in mind.
Most of the PPOs surveyed offered a wide range of
services (Table). Those plans which market a fixed
package of benefits tend to cover slightly fewer services
than average.
Under a preferred provider arrangement the pa-
tient's benefits may be more extensive (in that he may
receive first dollar coverage) if he uses the preferred
providers than if he goes to a nonpreferred provider
(in which case he is responsible for whatever ad-
ditional copayments or deductibles are stipulated in
the contract). In some cases, the PPO requires a nom-
inal copayment or deductible to be paid by the patient
even if he uses a preferred provider; however, even
under these plans the patient’s out-of-pocket costs are
still much greater if he goes to a nonpreferred provider.
Thus, a preferred provider arrangement provides ben-
efits regardless of whether the patient uses a preferred
or nonpreferred provider. An “Exclusive Provider Or-
ganization,” however, provides no benefit coverage at
all if the patient goes to any provider other than a
designated panel member. (There are veiy few of these
organizations being developed to date and several
states have laws specifically prohibiting the develop-
ment of such plans.)
Many plans also include contract provisions to en-
courage utilization of the outpatient setting rather
than the more costly inpatient setting for certain ser-
TABLE
List of Services Usually Covered
Under Preferred Provider Arrangements* *
• Physician services
• Inpatient care
• Outpatient care
• Emergency room care
• Mental health services
• Treatment-referral for alcohol and chemical dependence
• Diagnostic laboratory services
• Diagnostic and therapeutic x-ray services
• Well child care
• Health evaluation for adults
• Eye and ear examinations for children
• Immunizations
• Prescription drugs
• Durable medical equipment
• Prosthetic devices
Additional Services Often Covered
• Infertility services
• Long-term rehabilitative services
• Long-term care services
• Intermediate care services
‘Source: AMA Survey of PPOs, February-August 1983. It
is important to note that coverage levels will vary from one
PPO organization to another.
vices. For example, under some arrangements, speci-
fied services or procedures will not be covered unless
they are delivered or performed on an outpatient basis.
In other cases, the patient pays a higher copayment
or deductible for services which can be provided on an
outpatient basis if they are delivered in an inpatient
setting.
One of the reasons cited by physicians for joining
a PPO is their expectation of the potential for ad-
ditional patients and other advantages to be derived 1
from the marketing efforts of the PPO itself. This can
only be accomplished if the PPO has done a careful
market analysis and developed a marketing plan. The
market analysis should take into account the following
factors;
• Articulation of the potential demand or need for
a PPO in the area
• The extent of the planned service area
• An area employer profile.
• An analysis of the likelihood of penetrating this
market.
• The major payors in the area and their relative
market shares.
• An identification of potential major competitors.
Since the great majority of potential subscribers will
be enrolling through their place of work, it is import-
ant to acquire good information about the employed
population of the area. PPO developers must know:
• The number of employers in the area, categorized
by size of employee work force and type of work.
• Which insurance companies have the major share
of the market.
• The level of health benefits commonly offered by
employers.
• What the premium levels are.
• What portion of the premium is paid by the em-
ployer.
172
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The more specific information that can be acquired,
the more effective the marketing plan will be. Much of
the necessary information only can be obtained by
actually surveying the employers in the area.
The organization and implementation of a PPO does
not appear to require as sizable a capitalization as is
required to set up a Health Maintenance Organization.
Estimates of start-up costs among PPOs surveyed aver-
aged approximately $40,000, and ranged from zero to
i $200,000. Start-up costs are incurred primarily for
market analysis and actuarial consultants. In the case
of physician-sponsored PPOs, start-up costs usually
are financed by the physicians. If the plan does not
deliver results in terms of patient volume within the
projected start-up timeframe, these physicians may
risk an investment loss.
Once organized, a PPO also does not engender as
much overhead expense as an HMO. In part this is
because the PPO itself usually has a very small staff
serving as an intermediaiy broker between two already
established entities: the purchaser and a group of
providers (physicians and hospitals in the communi-
ty). There is no requirement for large offices or ex-
pensive equipment in such a contracting or brokering
arrangement. Most of the resources required by the
PPO are secured on a contract basis, not purchased
or leased. Often this includes data collection and
analysis systems contracted for through local insurers.
The PPO does serve some administrative and mar-
keting functions, however, for which payment must be
made. PPOs can and do charge their providers or their
purchasers or both, for the administrative services of
the PPO. If the purchasers are assessed a fee, it may
be on a percent of premium or a per subscriber basis.
Provider charges may take the form of a monthly mem-
bership charge, an inital entrance fee, or both.
In addition, while there has not been an infusion of
government funds into the development of these or-
ganizations, there have been some private funds from
such sources as large employers or insurance com-
panies interested in developing the concept. The Rob-
ert Wood Johnson Foundation recently awarded the
San Diego Committee for Affordable Care— a com-
munity-wide coalition of employers, consumers, un-
ions, and providers — a grant to develop an areawide
PPO.
Another characteristic of PPOs is the low level of
linaneial risk involved for the participating physician
in a plan which is reimbursed on a fee-for-service
basis. However, there are a few PPOs beginning now
to experiment with the notion of risk-sharing as an
added cost containment incentive. One example of this
type of plan is the Physician's Health Plan in Minne-
sota This plan pays participating physicians on a fee-
for-service basis, but retains 20 percent of the agreed
upon fees in an escrow fund. At the end of the year,
if promised savings have not been generated, these
funds must be shared with the purchasers. If savings
have accrued to the purchasers as promised, the funds
are divided among the participating physicians. At this
point, the distinguishing lines between PPOs and
HMOs begin to blur somewhat; the main difference
between an arrangement such as is described here and
an HMO, is that the PPO arrangement is not capitated.
Physician's Health Plan of Minneapolis is, in fact, a
long-established IPA which has begun to develop some
new business under a selective contracting mecha-
nism. Thus, a risk arrangement such as is described
is possible because the IPA is also an insurer and as
such is licensed by the state to collect and hold funds.
PPO failure can be considered within several con-
texts: failure to achieve the cost-containment objective
of the purchaser or organizational failure due either
to inadequate internal management or contractor fail-
ure. As with HMOs, failure can occur as the result of
purchaser failure, undercapitalization, or inadequate
management practices. Moreover, PPOs are a response
to competitive pressures. Their incentives operate in
a competitive climate and in the context of alternative
choices. Thus, the design of the PPO incentives relative
to other consumer options is very important. Financial
viability of PPOs is also an issue. PPOs, like other
health care delivery and financing plans, need to bal-
ance sound financial management against prudent
selection of purchaser groups and providers to help
prevent failure. Finally, there may be significant legal
issues to overcome, including antitrust issues for
which precedents have not yet been established.
FINI
Finding faults can be easy, if you forget your own.
VOL. 81— NUMBER 3— MARCH 1984
173
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Professional Liability
|
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l
A report of an ongoing study at-
tempting to identify the magni-
tude of the costs of professional
liability and to suggest their possible impact upon the
nation’s expenditures for health care has been re-
| leased. Commissioned by the AMA House of Delegates
at the 1982 Annual Meeting, the study is summarized
in a Board of Trustees report, which was referred for
consideration to Reference Committee H at the Los
Angeles Interim Meeting. The indepth study was con-
ducted by a Committee on Professional Liability ap-
pointed for the task and was chaired by John J. Couiy,
, Jr., M.D., a Trustee from Port Huron, Michigan.
The study estimated some of the direct and indirect
costs of professional liability in the medical and health
care sector, including:
• $1.43 billion to $1.47 billion paid by physicians in
1982 for professional liability insurance, with the pros-
f pect that their 1983 premiums will range from a pos-
sible $1.65 billion to as much as $1.75 billion.
• A comparable estimated expenditure by the na-
tion's hospitals for professional liability insurance
premiums or other protection against claims and
suits.
• An additional $2 million to $3 million paid out by
physicians in premiums to insure their skilled para-
medical employees against legal action.
• $15.1 billion in projected costs annually to pa-
tients for “defensive medicine” — additional tests arid
procedures that physicians sometimes prr< a j,;
response to the growing professional liability 1 :
Costs of professional liability protection ! >'
sicians, their skilled employees, and hospiCe.-
COMMENTARY*
Liability costs and
malpractice claims
Impact of Liability Costs Studied by
AMA; Malpractice Claims Increase to 8
Per 1 00 Physicians; Malpractice
Lawsuits Drive Up Ob-Gyn Fees; No
Lawsuit Against Hinckley Psychiatrist
estimated $3.5 billion in 1983. The projected cost of
$15.1 billion for defensive medicine represents about
5 percent of the nation’s 1982 medical care expen-
ditures of $322 billion.
Faced with the task of developing reasonable esti-
mates of costs for which no central sources of data are
available, the Committee on Professional Liability as-
sembled information from a variety of sources and
then made projections.
Since there is no national clearinghouse of infor-
mation on total premiums paid by individual phy-
sicians and groups for professional liability coverage,
estimates were made based upon data from the phy-
sician-owned insurance companies linked to medical
societies, from available information on commercial
carriers, from insurance company rate tables, and from
information obtained in July and August through
AMA’s Socioeconomic Monitoring System. Economists
and lawyers also provided input.
To calculate additional premium costs for covering
skilled paramedical employees employed by physicians,
the committee verified that the charge for protecting
these individuals adds about 2 percent to a physician s
insurance bill.
“A projection of $2 million to $3 million of added
premium costs could be estimated based upon approx-
imately $200 additional premium costs for each skilled
paramedic employed in physicians’ offices,” the Com-
mittee said. (American Medical News, December 2,
1983)
MALPRACTICE CLAIMS INCREASE
Information obtained from the AMA’s Socio-
economic Monitoring System (SMS) reveals that the
average incidence of claims per 100 physicians in-
creased from 3.3 claims per 100 physicians before
1978 to 8 claims per 100 physicians from 1978
through 1983. For certain surgical specialties at
greatest risk for suit, the claims per 100 physicians
range up to 11.8 per 100 physicians.
The SMS data also revealed that 12.5 percent of all
physicians sued hired a lawyer to defend them in ad-
dition to the lawyer provided by their insurance com-
pany. On average, each physician spent a total of 3.7
days giving depositions, making court appearances,
and meeting with attorneys over the last five years on
professional liability matters, or 2.7 days per claim.
The SMS survey of 1,240 physicians also sought
information about how they responded to increases in
professional liability risk. The most common physician
responses to the increasing risks of malpractice claims
have been to keep more detailed patient records (57
percent), to refer more patients to other physicians (45
percent), and to prescribe additional diagnostic tests
(41 percent). (American Medical News. December 2.
1983)
DID YOU KNOW . . .
Nationally, malpractice premiums for all physicians
added $5 a day to the cost of a hospital stay in 1982,
’This item from the Department of Professional Liability Con-
trol, MSNJ. was prepared by James E. George. M.D., J.D.. mid
A. Ronald Rouse who are. respectively, Director of the Depart-
ment and Director of Special Projects.
VOL. 81— NUMBER 3— MARCH 1984
175
and $2 to $4 to the cost of every visit to a doctor’s
office? (Medical Economics. December 12, 1983)
Today's medium outlay for malpractice coverage
comes to 3.5 percent of gross practice income com-
pared with 3 percent in the 1970s? ( Medical Eco-
nomics. November 28, 1983)
Southern California Physicians Insurance Exchange
will return $18 million in experience credits and repay
$1.3 million in contribution certificates to policy hold-
ers? The paybacks will offset a 7.5 percent rate in-
crease for 1984.
MALPRACTICE LAWSUITS DRIVE UP OB-GYN FEES
According to a recent survey by the American College
of Obstetricians and Gynecologists (ACOG), malprac-
tice lawsuits are driving up fees. In a poll of its mem-
bers, ACOG, found in California alone, obstetricians
and gynecologists have raised their fees up to 30 per-
cent over the past two years, in part because of in-
creases in professional liability insurance rates. The
survey also revealed that lawsuits against these
specialists are pushing health care costs upward be-
cause physicians are ordering more tests on patients
as a defense against litigation. Other survey results: in
1982, physicians and other health care providers paid
more than $1.7 billion in malpractice insurance
premiums, up 12 percent over 1981; ob-gyns pay the
most for malpractice insurance, with more than 30
percent nationally paying at least $15,000 each year
for coverage; and many ob-gyns are giving up their
obstetrical practice at a younger age primarily to avoid
the risk of lawsuits. (LACMA Physician. November 7,
1983)
NO LAWSUIT AGAINST HINCKLEY PSYCHIATRIST
A lawsuit against John W. Hinckley Jr.’s former psy-
chiatrist has been dismissed by a federal judge in Den-
ver. The lawsuit had been filed in United States Dis-
trict Court by three of the victims of Hinckley’s attempt!
to assassinate President Reagan on March 30, 1981,
including presidential secretary, James Brady. They
contended that Dr. John Hopper of Evergreen, Colo-
rado, who treated Hinckley for five months before the
attack, should have known that Hinckley would at-
tempt an act of violence.
United States District Court Judge John P. Moore
said: “Nowhere in the plaintiffs’ complaints are there
allegations that Hinckley made any threats regarding
President Reagan, or indeed that he ever threatened
anyone.”
At most, the judge said, the complaint states that if
the psychiatrist had interviewed Hinckley more closely,
he would have discovered circumstantial indicators of
future actions, such as his obsession with actress Jody
Foster and the movie “Taxi Driver," which involved a
political assassination attempt. (New Jersey Law
Journal, December 15, 1983)
n
176
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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178
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
> Production of patients' statements
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VOL. 81— NUMBER 3— MARCH 1984
179
Editorial
The Medical Society of New Jersey
is on the air! As participants of
the Healthcare Information
Network (HIN), MSNJ will be sponsoring closed-circuit
television programs related to issues and concerns of
physician members and New Jersey health care pro-
fessionals.
The live television shows will be presented to New
Jersey hospitals subscribing to the HIN closed-circuit
television network. HIN, the first statewide hospital
network to broadcast via satellite, began its operation
on January 4, 1984. HIN is an interactive, color tele-
vision system; the hub of the network is a central
telecommunications center and a satellite earth sta-
tion located in Princeton.
Presently, there are 18 hospitals participating in the
project: Beth Israel Hospital, Bridgeton Hospital, Clara
Maass Medical Center, Hackensack Medical Center,
Kessler Institute for Rehabilitation-Kessler West, Mem-
orial General Hospital, Morristown Memorial Hospital,
Muhlenberg Hospital, Newark Beth Israel Medical
Center, Northern Ocean Hospital System, Inc., Salem
County Memorial Hospital, St. Elizabeth Hospital, St.
Mary’s Hospital-Passaic, St. Peter’s Medical Center,
Underwood-Memorial Hospital, Warren Hospital, West
Hudson Hospital, and West Jersey Health System-
Northern and Eastern Divisions.
The programs will be viewed at 1 p m. on the first,
second, and third Tuesday of each month, in three
separate series:
1. President’s Forum: Hosted by Alexander D.
Kovacs, M.D. Dr. Kovacs will meet with selected mem-
bers of the MSNJ Board of Trustees and chairpersons
of various councils and committees to discuss infor-
mation presented at Board meetings. This program
will run on February 7, March 6, April 3, May 1, and
June 5.
2. The Impaired Physician: Conducted by David I.
Canavan, M.D., Medical Director of the Impaired Phy- 1
sicians Program, MSNJ. Dr. Canavan will describe all
aspects of the Impaired Physicians Program from a
definition of the problem to identification and confron- !
tation. This series will be on Januaiy 10, Februaiy 14, I
March 13, April 10, May 8, and June 12.
3. State of the Art: Moderated by Past President
Howard D. Slobodien, M.D. Dr. Slobodien will cover the
following subjects: Medicine: A Profession in Tran-
sition, Parts 1 and 2, with William Kane, M.D., Norval
Kemp, M.D., Alfred Alessi, M.D., Arthur Bernstein, M.D.,
and Frank Primich, M.D.; MSNJ Legislative Activities
with Irving Ratner, M.D., Mr. Joseph Katz, and Mr.
Edward Meara; The Medicaid Project with Thomas
Bellavia, M.D., Bayard Coggeshall, M.D., and Mr.
Thomas Russo; A Report from the AMA with William
D’Elia, M.D., and James Todd, M.D.; and Third-Party
Payor, with MSNJ Executive Director Vincent A.
Maressa, J.D. The programs will run on January 17,
February 21, March 20, April 17, May 15, and June 19.
All shows will be live, and viewer participation is
anticipated. During the program, an 800 number will
be flashed across the screen for individual calls.
Television programming is a new avenue for MSNJ.
The educational programs to be presented will allow
us to reach more of our membership. One possible way
would be for medical staffs to schedule a combined
lunch/HIN TV hour — and that way our members could
learn more about the profession straight from “the
horse’s mouth.” And, of course, MSNJ leadership
would be able to get a direct response from the
grassroots level.
MSNJ is keeping up with the times. Cable television
no longer is the way of the future: it is today’s medium
of communication. As they say in show biz, MSNJ is
"on line.” G.H.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
180
EDITORIAL
Dropping the Ball:
Tennis, Golf,
and Alcohol
William C. Van Ost, m.d., englewood
The American Medical Society on
Alcoholism has only 900 members. With
such a small membership, one wonders
where our professional sense of values
has gone. Physicians must be willing to
meet obligations and fight the epidemic
of alcohol and drug abuse.
I was leafing through the direc-
tory of medical organizations
which was published in the
April 22/29 1983, issue of JAMA (volume 249, no. 16),
when, near the end of page 2,154, I read a couple of
listings that really miffed me. No— the listings made
me feel damned mad: angiy enough to sit down and
share my opinion with any of my fellow physicians who
care to listen.
Listed just above the American Medical Tennis As-
sociation (3,300 members) and a bit below the Ameri-
can Medical Golf Association (1,300 members) is the
American Medical Society on Alcoholism with only 900
members. Not that I have anything against tennis or
golf, but it makes me wonder where our professional
sense of values has gone.
For example, there are 15 million kids in the world
out there who are living with an alcoholic parent;
millions more have reached adulthood bearing the scar
of their dysfunctional youth. At least a quarter of our
colleagues, if they would admit it, can identify with
that older group. Yet, only 5 percent of the population
in which alcohol is a central part of one’s life receives
any help, resulting in life-long feelings of anger, shame,
guilt, fear, and confusion. What are we physicians
doing to help alleviate at least some of the pain?
A recent Gallup poll revealed that over half of our
nation’s family members feel that they have in some
intimate way been affected by alcohol and drugs. The
17- to 24-year-old age group is the only portion of our
population which is experiencing an increasing mor-
tality rate mostly due to violent deaths as a result of
alcohol /drug-related traffic accidents, falls, drown-
ings, murders, and suicides.
We can stamp out polio, diphtheria and tetanus, and
erase smallpox from the face of the earth. Surely, these
are examples of preventive medicine at its best. Yet, we
allow over 1 10,000 people to die, directly or indirectly,
each year of the disease of alcoholism.
If just one person in your practice died of this
epidemic during the past year, what did you do to
prevent it? What could you have done? If either of the
parents was a drunk, you missed something. If there
was alcohol or drug use and you did not know it, you
apparently missed something. Why? Perhaps you just
did not look, or you did not listen, or you did not feel.
Most likely, you just did not ask. Too many of us look
upon alcoholism as an accusation, not as a disease; a
family disease which, unless diagnosed, destroys vic-
tim, family, friends, and neighbors. There is hope: Al-
coholism can be treated and it can be prevented if only
we physicians would turn aside our prejudices and use
our God-given senses to make the diagnosis, treat the
disease, and identify and treat the contacts, in an at-
tempt to put a stop to the epidemiological spread.
Get rid of the myths.
Alcoholism is not fussy. It affects rich, poor, black,
white, Christian, Moslem, and Jew.
A fact is a fact: One out of every four kids in every
practice involving children is depressed and confused
by the effects of family alcoholism. If you have not seen
them, you have not looked.
A child of an alcoholic is so filled with self-hate and
resentment that he may suffer headaches and ab-
dominal cramps, he may miss school, his grades may
drop, or he may try suicide. How can a thinking person
believe that it is the parent’s problem and not that of
the child?
If one really can buy the myth that a child from an
alcoholic home will ask for help if he really wants it,
then take a close look at the expression on the face of
a kid from an alcoholic home. Look into his eyes and
see the denial, the fears, and the held-back tears as he
fights to hide the family secret. You will not see it if
you do not ask the right question and look. How many
of us do?
I may be overreacting to that list which incurred my
wrath, but I know that a majority of physicians feel
that dealing with alcoholism and the family is someone
else’s job. How can one who has taken the Hippocratic
oath really avoid the cause of an ineestual pregnancy
or the brutal signs of child abuse?
The retreat behind the mythical wall that, somehow,
alcoholism is a personal matter is to ignore the ugly
alcohol- induced violence and the disastrous psycho-
logical effects on the family.
Society is calling for help — through television, radio,
newspapers, magazines. We see messages to us, the
members of the medical profession, to meet our obli-
gations and fight the epidemic of alcohol and drug
abuse. If our answer, due to whatever our ex-
cuse— prejudice, myths and fears — is in the negative,
then to the shame of our profession, society will turn
to others who already are doing and showing that they
really care.
VOL. 81— NUMBER 3— MARCH 1984
181
Treatment with Navane can produce improvement in
psychotic symptoms such as hallucinatory behavior and
unusual thought content as well as hostility, disorientation
and depressive mood,1 2 leaving the elderly patient more
alert2 and better able to participate in the activities of
Well tolerated
Navane is generally well tolerated by elderly patients.; $ ]
Excessive sedation or drowsiness has been reported, but
is uncommon.1 Anticholinergic effects3 and hypotension4 5
are reported, but rarely. Should they occur, extrapyramidal
symptoms can usually be readily controlled.
Navane
(thiothixene) (thiothixene HCI)
References: 1. Uti! TM, Unverdi C. Wohlrade J, el al: Drug therapy of psychosis associated with
organic brain syndrome. Presented as a Scientific Exhibit at the American Public Health Associa-
tion Centennial, Atlantic City, New Jersey, November 12-16. 1972. 2. Katz MM, Util TM: Video
methodology for research in psychopathology and psychopharmacology. Arch Gen Psychiatry
31:204-210, 1974. 3. Ketai R: Psychotropic drugs in the management ohpsychiatric emergencies.
Postgraduate Medicine 58:87-93, 1975. 4. Birkett DR Hirschfield W, Simpson GM: Thiothixene in
the treatment of diseases of the senium. Curr Ther Res 14:775-779, 1972. 5. Data on file at Roerig.
BRIEF SUMMARY OF PRESCRIBING INFORMATION
Navane’ (thiothixene) Capsules: 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
(thiothixene hydrochloride) Concentrate: 5 mg/ml, Intramuscular: 2 mg/ml, 5 mg/ml
Contraindications: Navane (thiothixene) is contraindicated in patients with circulatory collapse,
comatose states, central nervous system depression due to any cause, and blood dyscrasias.
Navane is contraindicated in individuals who have shown hypersensitivity to the drug. It is not
known whether there is a cross-sensitivity between the thioxanthenes and the phenothiazine
derivatives, but the possibility should be considered.
Warnings: Usage in Pregnancy — Safe use of Navane during pregnancy has not been established
Therefore, this drug should be given to pregnant patients only when, in the judgment of the
physician, the expected benefits from the treatment exceed the possible risks to mother and fetus
Animal reproduction studies and clinical experience to date have not demonstrated any
teratogenic effects.
In the animal reproduction studies with Navane, there was some decrease in conception rate
and litter size, and an increase in resorption rate in rats and rabbits, changes which have been
similarly reported with other psychotropic agents. After repeated oral administration of Navane to
rats (5 to 15 mg/kg/day), rabbits (3 to 50 mg/kg/day), and monkeys (1 to 3 mg/kg/day) before and
during gestation, no teratogenic effects were seen. (See Precautions.)
Usage in Children- The use of Navane in children under 12 years of age is not recommended
because safety and efficacy in the pediatric age group have not been established.
As is true with many CNS drugs, Navane may impair the mental and/or physical abilities required
for the performance of potentially hazardous tasks such as driving a car or operating machinery,
especially during the first few days of therapy. Therefore, the patient should be cautioned accord-
ingly
As in the case of other CNS-acting drugs, patients receiving Navane should be cautioned about
the possible additive effects (which may include hypotension) with CNS depressants and with
alcohol.
Precautions: An antiemetic effect was observed in animal studies with Navane, since this effect
may also occur in man, it is possible that Navane may mask signs of overdosage of toxic drugs and
may obscure conditions such as intestinal obstruction and brain tumor.
In consideration of the known capability of Navane and certain other psychotropic drugs to
precipitate convulsions, extreme caution should be used in patients with a history of convulsive
disorders or those in a state of alcohol withdrawal since it may lower the convulsive threshold.
Although Navane potentiates the actions of the barbiturates, the dosage of the anticonvulsant
therapy should not be reduced when Navane is administered concurrently.
Caution as well as careful adjustment of the dosage is indicated when Navane is used in
conjunction with other CNS depressants other than anticonvulsant drugs.
Though exhibiting rather weak anticholinergic properties, Navane should be used with caution
in patients who are known or suspected to have glaucoma, or who might be exposed to extreme
heat, or who are receiving atropine or related drugs.
Use with caution in patients with cardiovascular disease.
Also, careful observation should be made for pigmentary retinopathy, and lenticular pigmenta-
tion (fine lenticular pigmentation has been noted in a small number of patients treated with Navane
for prolonged periods). Blood dyscrasias (agranulocytosis, pancytopenia, thrombocytopenic
purpura), and liver damage (jaundice, biliary stasis) have been reported with related drugs.
Undue exposure to sunlight should be avoided. Photosensitive reactions have been reported in
patients on Navane.
Neuroleptic drugs elevate prolactin levels; the elevation persists during chronic administration.
Tissue culture experiments indicate that approximately one-third of human breast cancers are
prolactin dependent in vitro, a factor of potential importance' if the prescription of these drugs is
contemplated in a patient with a previously detected breast cancer. Although disturbances such
as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the clinical
significance of elevated serum prolactin levels is unknown for most patients. An increase in
mammary neoplasms has been found in rodents after chronic administration of neuroleptic drugs.
Neither clinical studies nor epidemiologic studies conducted to date, however, have shown an
association between chronic administration of these drugs and mammary tumorigenesis; the
available evidence is considered too limited to be conclusive at this time.
Intramuscular Administration — As with all intramuscular preparations, Navane Intramuscular
should be iniected well within the body of a relatively large muscle. The preferred sites are the
upper outer quadrant of the buttock (i.e. gluteus maximus) and the mid-lateral thigh.
The deltoid area should be used only if well developed, such as in certain adults and older
children, and then only with caution to avoid radial nerve injury. Intramuscular injections should not
be made into the lower and mid-thirds of the upper arm. As with all intramuscular injections,
aspiration is necessary to help avoid inadvertent injection into a blood vessel.
Adverse Reactions: Note: Not all of the following adverse reactions have been reported with
Navane (thiothixene). However, since Navane has certain chemical and pharmacologic similarities
to the phenothiazines, all of the known side effects and toxicity associated with phenothiazine
therapy should be borne in mind when Navane is used.
Cardiovascular effects: Tachycardia, hypotension, lightheadedness, and syncope. In the event
hypotension occurs, epinephrine should not be used as a pressor agent since a paradoxical
further lowering of blood pressure may result. Nonspecific EKG changes have been observed in
some patients receiving Navane. These changes are usually reversible and frequently disappear
on continued Navane therapy. The incidence of these changes is lower than that observed with
some phenothiazines. The clinical significance of these changes is not known.
CNS effects: Drowsiness, usually mild, may occur although it usually subsides wtih continuation
of Navane therapy The incidence of sedation appears similar to that of the piperazine group of
phenothiazines, but less than that of certain aliphatic phenothiazines. Restlessness, agitation and
insomnia have been noted with Navane (thiothixene). Seizures and paradoxical exacerbation of
psychotic symptoms have occurred with Navane infrequently.
Hyperreflexia has been reported in infants delivered from mothers having received structurally
related drugs
In addition, phenothiazine derivatives have been associated with cerebral edema and cere-
brospinal fluid abnormalities
Extrapyramidal symptoms, such as pseudo-parkinsonism, akathisia, and dystonia have been
reported. Management of these extrapyramidal symptoms depends upon the type and severity.
Rapid relief ot acute symptoms may require the use of an injectable antiparkins.on agent. More
slowly emerging symptoms may be managed by reducing the dosage of Navane and/or adminis-
tering an oral antiparkinson agent.
Persistent Tardive Dyskinesia: As with all antipsychotic agents tardive dyskinesia may appear in
some patients on long term therapy or may occur after drug therapy has been discontinued. The
risk seems to be great'1 r in elderly patients on high-dose therapy, especially females. The symp-
toms are persistent and in some patients appear to be irreversible. The syndrome is characterized
by rhythmical involuntary movements of the tongue, face, mouth or jaw (e.g., protrusion of tongue,
puffing of cheeks, puckering of mouth, chewing movements). Sometimes these may be accom-
panied by involuntary movements of extremities.
Capsules
available in
5 strengths
1 mg
2 mg
— ‘ ml
5 mg
10 mg
20 mg
' - w
Concentrate
5 mg/ml
NDC 0049-5750-1’
I Navane
• Mothixene HO
CONCENTRATE
5 mg / ml *
1 Mm)
-ACTION: F«*>raj tew prOU***
•-ww* mg without funcrtphV'
Intramuscular
2 mg/ml
5 mg/ml
h
I -
There is no known effective treatment for tardive dyskinesia; antiparkinsonism agents usually do :
not alleviate the symptoms of this syndrome. It is suggested that all antipsychotic agents be
discontinued if these symptoms appear
Should it be necessary to reinstitute treatment, or increase the dosage of the agent, or switch to a j
different antipsychotic agent, the syndrome may be masked.
It has been reported that fine vermicular movements of the tongue may be an early sign of the j
syndrome and if the medication is stopped at that time, the syndrome may not develop.
Hepatic effects: Elevations of serum transaminase and alkaline phosphatase, usually transient,
have been infrequently observed in some patients. No clinically confirmed cases of jaundice
attributable to Navane (thiothixene) have been reported.
Hematologic effects: As is true with certain other psychotropic drugs, leukopenia and
leukocytosis, which are usually transient, can occur occasionally with Navane. Other antipsychotic
drugs have been associated with agranulocytosis, eosinophilia, hemolytic anemia, throm-
bocytopenia and pancytopenia.
Allergic reactions: Rash, pruritus, urticaria, photosensitivity and rare cases of anaphylaxis have (
been reported with Navane. Undue exposure to sunlight should be avoided. Although not experi- j
enced with Navane, exfoliative dermatitis and contact dermatitis (in nursing personnel) have been I
reported with certain phenothiazines
Endocrine disorders: Lactation, moderate breast enlargement and amenorrhea have occurred
in a small percentage of females receiving Navane. If persistent, this may necessitate a reduction
in dosage or the discontinuation of therapy. Phenothiazines have been associated with false
positive pregnancy tests, gynecomastia, hypoglycemia, hyperglycemia, and glycosuria.
Autonomic effects: Dry mouth, blurred vision, nasal congestion, constipation, increased sweat- '
ing, increased salivation, and impotence have occurred infrequently with Navane therapy. \
Phenothiazines have been associated with miosis, mydriasis, and adynamic ileus.
Other adverse reactions: Hyperpyrexia, anorexia, nausea, vomiting, diarrhea, increase in appe-
tite and weight, weakness or fatigue, polydipsia and peripheral edema
Although not reported with Navane, evidence indicates there is a relationship between 1
phenothiazine therapy and the occurrence of a systemic lupus erythematosus-like syndrome.
NOTE: Sudden deaths have occasionally been reported in patients who have received certain I
phenothiazine derivatives. In some cases the cause of death was apparently cardiac arrest or 1
asphyxia due to failure of the cough reflex. In others, the cause could not be determined nor could
it be established that death was due to phenothiazine administration.
Dosage and Administration: Dosage of Navane should be individually adjusted depending on the
chronicity and severity of the condition. In general, small doses should be used initially and I
gradually increased to the optimal effective level, based on patient response.
Some patients have been successfully maintained on once-a-day Navane therapy.
Usage in children under 12 years of age is not recommended because safe conditions for its use
have not been established
Navane Intramuscular Solution: Navane For Injection— Where more rapid control and treatment
of acute behavior is desirable, the intramuscular form of Navane may be indicated It is also of
benefit where the very nature of the patient's symptomatology, whether acute or chronic, renders
oral administration impractical or even impossible.
For treatment of acute symptomatology or in patients unable or unwilling to take oral medication,
the usual dose is 4 mg of Navane Intramuscular administered 2 to 4 times daily. Dosage may be
increased or decreased depending on response. Most patients are controlled on a total daily
dosage of 16 to 20 mg. The maximum recommended dosage is 30 mg/day. An oral form should j
supplant the injectable form as soon as possible. It may be necessary to adjust the dosage when :
changing from the intramuscular to oral dosage forms. Dosage recommendations for Navane i
(thiothixene) Capsules and Concentrate appear in the following paragraphs.
Navane Capsules: Navane Concentrate - In milder conditions, an initial dose of 2 mg three times j
daily. If indicated, a subsequent increase to 15 mg/day total daily dose is often effective.
In more severe conditions, an initial dose of 5 mg twice daily.
The usual optimal dose is 20 to 30 mg daily. If indicated, an increase to 60 mg/day total daily
dose is often effective. Exceeding a total daily dose of 60 mg rarely increases the beneficial
response.
Overdosage: Manifestations include muscular twitching, drowsiness, and dizziness. Symptoms of
gross overdosage may include CNS depression, rigidity, weakness, torticollis, tremor, salivation,
dysphagia, hypotension, disturbances of gait, or coma
Treatment: Essentially is symptomatic and supportive. For Navane oral, early gastric lavage is
helpful. For Navane oral and Intramuscular, keep patient under careful observation and maintain
an open airway, since involvement of the extrapyramidal system may produce dysphagia and :
respiratory difficulty in severe overdosage. If hypotension occurs, the standard measures for
managing circulatory shock should be used (IV fluids and/or vasoconstrictors )
If a vasoconstrictor is needed, levarterenol and phenylephrine are the most suitable drugs.
Other pressor agents, including epinephrine, are not recommended, since phenothiazine deriva-
tives may reverse the usual pressor action of these agents and cause further lowering of the blood
pressure
If CNS depression is present and specific therapy is indicated, recommended stimulants
include amphetamine, dextroamphetamine, or caffeine and sodium benzoate Stimulants that
may cause convulsions (e g. picrotoxin or pentylenetetrazol) should be avoided Extrapyramidal
symptoms may be treated with antiparkinson drugs.
There are no data on the use of peritoneal or hemodialysis, but they are known to be of little value
in phenothiazine intoxication.
ROeRIG<®
A division of Pfizer Pharmaceuticals
184
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Hospital
Governing Boards*
Should Certificate of
Need Legislation
Be Repealed?
Vincent A. Maressa, j.d.
Health service researchers have begun
to question the assumptions underlying
the certificate of need concept. New
Jersey is seriously considering
expanding its certificate of need law to
remove the current exemption granted
to physicians in their private practices.
Certificate of need laws were de-
signed to combat spiraling
health care costs and the un-
necessary duplication and maldistribution of health
care facilities and services. Health service researchers
in several disciplines have begun to question many of
the assumptions underlying the certificate of need
concept. While this is occurring. New Jersey which has
a penchant for being different is seriously considering
expanding its certificate to need law to remove the
current exemption granted physicians in their private
practices. The Blue Ribbon Committee to the State
Health Coordinating Council has recommended this
action without any objective documentation of its ad-
visability, or for that matter a clear understanding of
the problem.
The Utah Law Review, Volume 1978, Number 1, pub-
lished by the University of Utah College of Law con-
tains a series of papers on the certificate of need mech-
anism.
The first paper presents an overview and was written
by James F. Blumstein, Professor of Law, Vanderbilt
Law School and Frank A. Sloan, Professor of Eco-
nomics, Vanderbilt University. The work on the article
was supported in part by the Vanderbilt Institute for
Public Policy Studies and by Grant No. 7-ROl-HS
02590 from the National Center for Health Services
Research, United States Department of Health and
Human Services.
The authors begin by citing a number of defects in
our health care system which led to increased costs.
They then point out that while the defects are widely
recognized, not all agree the solution is to impose
rationing on the health “nonsystem” through a cen-
tralized bureaucratic system of controls. They indicate
that the research community interested in the effects
of certificate of need legislation has developed and
sought the answers to a series of questions. They state
that research findings on the effects of certificate of
need must be considered very tentative and often are
contradictory.
They conclude by stating, “While we are forced to
hedge somewhat since some indepth research is still
in progress, it is fairly safe to conclude that the
certificate of need review will at best make a minor
contribution to tempering the rate of rising health care
costs Moreover, the certificate of need may not turn
out to achieve the cost-containment objectives its
proponents had anticipated.”
It is this writer’s belief that the predictions of Blum-
stein and Sloan published in 1978 have indeed come
to pass. The Health Department in New Jersey re-
cognizes that the certificate of need has not delivered
what was promised. It, however, believes the solution
rests in expansion of jurisdiction. On the other hand,
the Commissioner of Health declared on October 25,
1983, that New Jersey has 30 percent more acute hos-
pital beds than it needs. If the certificate of need pro-
cess held any promise, it was in controlling the
number of hospitals beds. As the Commissioner in-
dicated, it has been a dismal failure in that regard.
Certainly, it is time for hospital governing boards,
hospital management, the medical community, and
the patient population to re-evaluate the certificate of
need concept and to make their views known to the
Department of Health and the legislature. The Depart-
ment should conduct some serious introspective re-
flection to ascertain what purpose has been served by
the certificate of need exercise other than the employ-
ment of planners.
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, J.D.,
Executive Director, MSNJ; and James E. George, M.D., J.D.,
Director of Professional Liability, MSNJ.
VOL. 81— NUMBER 3— MARCH 1984
185
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Psychological Effects
of Rhinoplasty
Alvin I. Glasgold, m.d., and Susan B. Horowitz, ph.d., new Brunswick
Assessing the psychological and social consequences of
rhinoplasty , 139 patients were mailed questionnaires to measure
change in three areas: attitudes towards physical appearance ,
self-esteem , and social relationships . A majority of patients
reported increased self-esteem and improved attitudes .
A recent article in the science sec-
tion of The New York Times in-
dicated that attractive people
are perceived as more poised, sensitive, sincere, in-
telligent, and successful than others.1 Along with the
recent increase in publicity about cosmetic surgery,
this would tend to reinforce the positive value of this
type of surgery. If this is true, do people who undergo
a change in appearance equally change in a positive
psychological sense? Are they perceived differently? Do
they make social gains? Do they change in their rela-
tionships to friends and family?
Since the 1940s, numerous studies have focused on
the motivations and characteristics of individuals
seeking rhinoplasty. Several researchers report a high
degree of emotional disturbance among the population
seeking rhinoplasty.2 4 A common psychiatric view-
point, based on unconscious conflict and symptom
substitution, suggests that rhinoplasty is likely to have
an unpredictable, negative psychological effect or, at
best, no effect at all.5 7 In May 1980, Shulman discussed
assessment of the prospective rhinoplasty patient in
terms of psychopathology, emphasizing the need for
routine psychiatric screening.7
Researchers may have been overly concerned with
documenting the motivations and psychiatric symp-
tomatology of candidates for rhinoplasty as opposed to
focusing on the psychological and social gains actually
made following surgery. This study considers the ques-
tion of positive psychological change which follows
cosmetic rhinoplasty. The researchers attempt to
answer the following questions: Are patients satisfied
with the results of their surgery? Are there specific
psychological changes in patients following rhinoplas-
ty? What is the significance of the patient’s
preoperative expectations?
METHODS
In April 1979, questionnaires were mailed to 254
former patients who had rhinoplasty operations be-
tween September 1976 and September 1978. Com-
pleted questionnaires were received from 106 patients.
A random sample of 33 patients who did not respond
to the mailed questionnaire were contacted by phone.
Their responses were similar to the larger sample who
responded to mailed questionnaires.
The total sample consisted of 139 patients (31 men
and 108 women) ranging in age from 15 to 57 years
old. At least six months elapsed between a patient’s
rhinoplasty and the arrival of the questionnaire. This
*Dr. Glasgold is Chairman, Department of Otolaryngology-
Head and Neck Surgery, St. Peter's Medical Center and
Middlesex General-University Hospital, New Brunswick. Dr.
Horowitz is affiliated with Rutgers University, Graduate
School of Social Work. New Brunswick. Correspondence may
be addressed to Dr. Glasgold, 31 River Road, Highland Park,
NJ 08904.
VOL. 81— NUMBER 3— MARCH 1984
187
TABLE 1
Average Levels of Satisfaction for
Age Group with Rhinoplasty
20 Age
n = 106
0= Minimum level of satisfaction
10= Maximum level of satisfaction
timing deliberately was designed to give patients
ample time to resume their personal lives following
surgery and for postoperative swelling to diminish.
Patients who explained that their rhinoplasty was due
to trauma or breathing difficulty, denying cosmetic
motivation, were eliminated from the study.
THE QUESTIONNAIRE
The questionnaire focused on three areas: patient
satisfaction with the results of rhinoplasty: level of
psychological change following rhinoplasty: and pa-
tient expectations prior to rhinoplasty surgery.
In order to measure satisfaction with rhinoplasty,
patients were asked to rate their level of satisfaction
with cosmetic results on a 0 to 10 point scale. To
measure the level of psychological change following
rhinoplasty, 15 questions were used to assess a given
patient’s attitude towards appearance, sense of self-
esteem, and behavior in social situations. The average
of changes in these three areas is referred to as a
patient’s psychological change score.
Patient expectations prior to rhinoplasty were
assessed in two ways: in terms of psychological expec-
tations dealing with possible differences in a person’s
feeling of attractiveness, popularity, self-confidence
and social relationships which might take place follow-
ing rhinoplasty, and physical expectations aimed
specifically at the patient’s imagined idea of what the
face and nose would like following surgery. A 0 to 10
point scale again was utilized to measure both levels
of expectations.
ANALYSIS OF DATA
The first factor that was analyzed was patient satis-
faction with the results of rhinoplasty.
Data analysis revealed that an overwhelming ma-
jority of patients were very satisfied with the results
ol rhinoplasty. On a 0 to 10 point scale where 10 rep-
resents maximum satisfaction with results, the mean
level of patient satisfaction was 9.5 with the modal
(most frequent) response being 10.
Although we expected responses indicating general
satisfaction, we were surprised by the high level of
satisfaction. Table 1 indicates a breakdown according
to age with some slight increase in satisfaction in the
older age group. Because of the almost universal
response, further demographic breakdown was not in-
dicated.
In order to test the hypothesis that positive psycho-
logical change takes place following rhinoplasty, the
psychological change scores of patients were analyzed.
Three specific areas of change were identified: im-
provements in attitudes towards physical appearance;
improvements in self-esteem: and improvements in
social relationships.
Using statistical analysis (t tests and ANOVA), age
was found to be a significant variable (P<. 03) particu-
larly in the area of improved social relationships.
Younger patients, specifically under age 30, demon-
strated greater gains in social relationships following
rhinoplasty than did older patients. The 15- to 19-year-
old age group showed the greatest gain in this area.
Table 2 shows that the greatest positive psychologi-
cal change occurs with respect to patients’ attitudes
towards their physical appearance. This is true for all
age categories.
Moderate improvements in self-esteem and social
relationships also take place for all age groups. It
should be noted that the youngest age group, 15 to 19
years old, made the greatest improvements in all three
areas of psychological change following rhinoplasty.
Table 3 considers the psychological and physical ex-
pectations of rhinoplasty patients before their surgery.
As a group, prospective rhinoplasty patients had
moderately low expectations for psychological change
following their surgery. It should be noted here that
age is a significant variable in this (P<.02) indicating
that the younger patients showed higher levels or pro-
jected changes in their lives as a consequence of
rhinoplasty. Again, the 15- to 19-year-old age group
showed the highest level of psychological expectations
as to possible life changes following surgery.
Items labeled as physical expectations refer to the
patient’s expectation of what the face and nose would
actually look like after rhinoplasty. Data revealed that
most patients did not expect to look perfect and most
had no specific or rigid idea of what their nose would
look like before surgery. This was true for all patients
with no significant difference noted for any age group.
The fact that the youngest group of patients had the
highest psychological expectations for their rhinoplas-
ty is interesting in light of the previous findings that
the younger group actually accomplished the greatest
psychologic gains in all areas tested, namely attitude
towards appearance, self-esteem, and social rela-
tionships. It appears that younger patients who have
moderately high expectations prior to rhinoplasty, as
a group, follow through after surgery to make signifi-
cant positive psychological gains.
When a patient’s psychological expectations were
correlated with total psychological change scores fol-
lowing rhinoplasty, r=.66. In other words, moderately
high patient expectations prior to rhinoplasty may be
related to actual level of change following surgery. Per-
haps the traditional viewpoint of skeptically viewing
high patient expectations as an indicator of potential
patient dissatisfaction needs to be seriously
challenged.
188
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 2
Average Psychological Change Scores for Age Groups
Age
(18)
15 to 19
(41)
20 to 29
(26)
30 to 39
(11)
40 to 49
(10)
50+
Total
Physical Appearance
8.5
7.1
7.5
6.5
7.4
7.4
Self-Esteem
7.3
5.6
6.2
5.1
5.3
6.0
Social Relationships
7.5
4.7
5.2
4.4
4.1
5.2
(Average) Psychological
Change Score
7.7
5.8
6.3
5.3
5.6
6.2
n = 1 06
0=Minimum level of satisfaction
10 = Maximum level of satisfaction
TABLE 3
Average Expectations and Age Levels of
Rhinoplasty Patients Before Surgery
Age
Psychological
Expectation
Level
Physical
Expectation
Level
Under
20
5.6
4.5
20 to 29
3.3
5.6
30 to 39
3.3
3.7
40 to 49
3.9
5.7
50+
2.5
3.8
Average
3.7
4.8
0 = Minimum level of expectation
10= Maximum level of expectation
CONCLUSIONS
This study tests the hypothesis that there is positive
psychological change following cosmetic rhinoplasty.
Data indicate that patients do make moderate gains
in three areas. The most outstanding changes are in
attitudes towards physical appearance, but there are
moderate gains made in self-esteem and social rela-
tionships as well.
It is significant that the younger age group achieved
the greatest changes. This indicates the importance of
establishing a positive physical self-image during the
period of emotional and social maturation. The fact
that the older age group achieved some changes sug-
gests the importance of the role of physical appearance
throughout life.
With respect to the level of psychological expecta-
tions prior to rhinoplasty, age was a significant vari-
able. Younger patients had higher expectations of pro-
jected social and psychological changes in their lives
prior to rhinoplasty. High expectations prior to
rhinoplasty were correlated positively with the actual
level of psychological change taking place following
surgery. The younger patient who has fairly high hopes
following rhinoplastic surgery does in fact achieve this
change in self-image, as does the older patient to a
somewhat lesser degree. Furthermore, this suggests
that the patient with a high expectation level neces-
sarily is not an added risk in terms of dissatisfaction
with results.
In view of the literature focusing on patient per-
sonality disorders, the fact that we noted such a high
level of patient satisfaction is encouraging, particularly
in that there was no preoperative psychological evalu-
ation of these patients beyond the routine consul-
tation.
In summary, the overwhelming majority of patients
sampled in this study were subjectively satisfied with
their results. Given patient satisfaction, significant
psychological and social changes do take place follow-
ing rhinoplasty particularly in the younger age group.
Attitudes toward physical appearance are enhanced
greatly for all patients with moderate improvements in
self-esteem and social relationships as well.
REFERENCES
1. Brody E: Effects of beauty found to run surprisingly
deep. The New York Times: C1-C3, 1981.
2. Linn L, Goldman IB: Psychiatric observations concern-
ing rhinoplasty. Psychosom Med 41:307-314, 1949.
3. Edgerton M, Jacobson W, Meyer E: Surgical-psychiatric
study of patients seeking plastic surgery. Br Plastic Surg
13:279-281, 1960.
4. Hay GG: Pyschiatric aspects of cosmetic nasal oper-
ations. Am J Psych 116:85-97, 1970.
5. Jacobson W, Edgerton M. Meyer E, Psychiatric evalu-
ation of male patients seeking cosmetic surgery. Plast Re-
constr Surg 25:356-373, 1960.
6. Hill G, Silver AG, Edgerton M: Psychodynamic and
aesthetic motivations for plastic surgery. Psychosom Med
14:345-356, 1950.
7. Shulman H: Psychiatric assessment of the candidate for
cosmetic surgery. Otolaryngol Clin North Am 12:383-389,
1980.
VOL. 81— NUMBER 3— MARCH 1984
189
Radionuclide Testicular Scanning
John L. McCormack, m.d., long branch*
Thirty-two patients underwent testicular scanning with
99mtechnetium pertechnetate. Results compare favorably with the
literature. This radiographic technique is a reliable means to
evaluate the patient with testicular pain.
Numerous studies in surgical,
pediatric, and nuclear medicine
literature have shown radionu-
clide scanning of the scrotum to be a safe, effective, and
relatively noninvasive technique of evaluating the male
patient with testicular pain. The studies have
demonstrated that in the patient with equivocal
findings on physical and laboratory examination,
dynamic and static scanning with ""Technetium
pertechnetate reliably can differentiate between
conditions requiring surgical intervention and those
amenable to medical therapy.16 Our experience at
Monmouth Medical Center, Long Branch, is consistent
with these results.
METHODS
Patients assume a supine position under a single
crystal gamma camera with pinhole eollimation. A
bolus of ""Technetium pertechnetate is injected
intravenously in a dose ranging from 8 to 10 mCi (296
to 370 MBq), depending on the patient’s weight.
Dynamic scanning of the inguinal region is performed,
obtaining sequential two-second images for a total of
2 minutes. A lead drape then is placed under the
scrotum to shield out thigh activity: anterior static
images are obtained at 5, 10, and 15 minutes after
injection of the radiopharmaceutical. Simultaneous
acquisition of the data by a General Electric computer
provides a means of quantitatively analyzing the
radioactivity within the scrotum.
RESULTS
Patterns of activity within the scrotum have been
well described in the literature for various condi-
tions.2-46-7 Normally, blood flow to the scrotum as seen
on dynamic scanning is symmetrical from side to side
as is the activity within the scrotum on static imaging ;
(Figure 1). Inflammatory processes such as
epididymitis and orchitis are associated with
unilaterally increased activity on the affected side on
both dynamic and static images (Figure 2). An acute
testicular torsion will result in decreased activity on
the affected side on both phases of the scan (Figure j
3A). Other conditions requiring surgical treatment
such as testicular torsion of several days duration
(“missed” testicular torsion) and scrotal abscess may
show increased activity on the affected side during the
dynamic study, whereas static images generally will
show a peripheral rim of increased activity
surrounding an area of abnormally low activity in that
side of the scrotum (Figures 3B, 3C, and 4). A similar
pattern has been described related to testicular
rupture following blunt scrotal trauma.8
‘From the Department of Diagnostic Radiology. Monmouth
Medical Center, Long Branch. Correspondence may be
addressed to Dr. McCormack, Department of Diagnostic
Radiology, Monmouth Medical Center, 300 Second Avenue,
Long Branch, NJ 07740.
190
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
B
Figure 1 — Normal 99mtechnetium pertechnetate testicular Figure 2 — Increased activity on left side of scrotum (arrows)
scan; A: dynamic images, and B: static images. on both dynamic (A) and static (B) images: inflammatory
process.
TABLE
Results of"mTechnetium Pertechnetate Testicular Scanning: Monmouth Medical Center
November 1980- December 1982
Scan Findings
No. of Patients
Clinical Outcome
No asymmetry in
activity
3
2 recovered with medical
therapy
1 torsed viable testicle at
surgery
Increased activity
affected side on
static and dynamic
images
19
All recovered with medical
therapy
Decreased activity
affected side on
static and dynamic
images
2
1 torsed viable testicle at
surgery
1 torsed necrotic testicle,
orchiectomy
Rim of increased
activity, central
decreased activity
on affected side,
static and dynamic
or static alone
4
2 torsed necrotic testicle,
orchiectomy
1 torsed viable testicle
1 no information available
Minimal decreased
activity on
affected side
static and/or
dynamic images
4
1 torsion of appendix
testis at surgery
1 incomplete testicular
torsion at surgery
1 benign inflammatory cyst
with hemorrhage
1 no information available
VOL. 81— NUMBER 3— MARCH 1984
191
Figure 3A — Patient presented with acute onset of left
testicular pain; initial static images reveal decreased activity
on left side of scrotum (arrow). Surgery is not performed
immediately due to suspicion of undescended left testicle as
cause of asymmetrical activity.
B
Figure 3B — Same patient underwent repeat scan three days
after initial study; rim of increase activity after central areas
of decreased activity noted on left (arrow). Torsed but viable
testicle found at surgery.
Figure 3C — Followup scan eight weeks after surgery revealed
symmetrical activity.
From November 1980 through December 1982, 32
patients underwent radionuclide testicular scanning
at Monmouth Medical Center. Of these studies, 19
were indicative of an inflammatory process; all of these
patients were successfully treated medically as in- or
outpatients, and none required surgery. Two patients
who had normal scans were managed conservatively.
The scans of six patients unequivocally demon-
strated conditions that necessitated surgery. Each of
two patients was found to have a torsed but viable
testicle at surgery. In each of the three patients, a
necrotic testicle was discovered resulting in unilateral
orchiectomy. Information on one patient was
unavailable.
Five other patients demonstrated a variety of
findings. Scanning was normal on one patient who,
due to clinical findings and the absence of signs of an
inflammatory process on the radionuclide study, was
taken to surgery where a torsed but viable testicle was
found. Minimal asymmetry in activity was noted on
scanning the other four patients in this group, all of
B
Figure 4— Increased flow to left side of scrotum on dynamic
(A) imaging in a patient treated for inflammatory process for
four days based on physical and laboratory findings. Central
decreased activity noted on left with rim of increased activity
on static images (B) (arrows). Necrotic left testicle removed
at surgery.
whom subsequently underwent surgery. One patient
had torsion of the appendix testis; another had an
incomplete testicular torsion; in a third patient, a
benign inflammatory cyst was encountered that had
hemorrhaged. Information on the fourth patient was
unavailable (Table).
DISCUSSION
Clinical differentiation of acute testicular torsion, as
well as other surgical conditions affecting the testes
and scrotum, from medically treatable illnesses can be
difficult. While fever, leukocytosis, and pyuria are
considered more likely to indicate inflammatory
process, these signs will not exclude the presence of
scrotal abscess. Furthermore, the signs noted above do
not necessarily exclude testicular torsion.4910 While
torsion occurs most commonly between the ages of 12
and 18 years, it has been described in patients aged
68 years.911 Physical examination may yield
ambiguous results and may be quite difficult to
perform owing to the pain and tenderness which may
accompany either an inflammatory process or acute
torsion.411
Testicular blood flow has been studied by means of
the Doppler ultrasonic flowmeter in order to diagnose
acute testicular torsion without an invasive procedure.
However, this method has not proved as reliable in
differentiating acute torsion from other conditions
associated with scrotal pain and is unable to
distinguish medically treatable causes of scrotal
192
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
hyperemia from those requiring surgery.3 v :'< As
described previously, radionuclide scanning can make
this distinction.
Early diagnosis, particularly in the case of acute
testicular torsion, is imperative to preserve testicular
function. Absence of spermatogenesis has been
demonstrated experimentally after four hours of
complete ischemia; Sertoli and Leydig cells appear
somewhat more resistant to the effects of ischemia.15
Overall, testicular viability has been reported to be 80
to 100 percent when torsion is corrected within six
hours of the onset of symptoms.16 Furthermore, as the
anatomic defect allowing the testicle to twist is
bilateral in the majority of eases, identification of the
patient with torsion indicates the need for surgical
fixation of the nontorsed testicle.1011 Obviously,
radionuclide scan evidence of a nonsurgieal disorder
precludes surgical exploration in the patient in whom
this is unnecessary.
SUMMARY
Dynamic and static imaging of the scrotum with
"mtechnetium pertechnetate is an effective means of
evaluating the patient with acute scrotal pain. In the
patient in whom the physical and laboratory
examinations are equivocal, radionuclide scanning
may differentiate conditions requiring surgery from
those amenable to medical therapy. Rapid identifi-
cation and surgical correction of acute testicular tor-
sion is necessary to preserve testicular function, while
patients with uncomplicated inflammatory conditions,
such as epididymitis and orchitis, should not be sub-
jected to surgery in order to rule out torsion as the
etiology of their symptoms. Therefore, radionuclide tes-
ticular scanning should be performed in suspect cases
emergently. When the study is not available on such
a basis, patients immediately should be referred to an
institution where this study can be performed as early
as possible.
REFERENCES
1. Hahn LC, Nadel NS, Gitter NH, Vernon AR Testicular
scanning: A new modality for the preoperative diagnosis of
testicular torsion. J Urol 113:60-62, 1975.
2. Boedecker RA Sty JR Jona LZ: Testicular scanning as
a diagnostic aid in evaluating scrotal pain. J Pediatrics
94:760-762. 1979.
3. Smith SP, King LR Torsion of the testis: Techniques of
assessment. Urol Clin North Am 6:429-443, 1979.
4. Stage KH, Schoenvogel R Lewis S: Testicular scanning:
Clinical experience with 72 patients. J Urol 125:334-337,
1975.
5. Vordermark JS, Buck AS, Brown SR Tuttle WR The
testicular scan: Use in diagnosis and management of acute
epididymitis. JAMA 245:2512-2514, 1981.
6. Thomas WEG, Cooke PH, Davies ER Jackson PC,
Williamson RCN: Dynamic radionuclide scanning of the testis
in acute scrotal conditions. Br J Surg 68:621-624, 1981.
7. Datta NS, Mishkin FS: Radionuclide imaging in
intrascrotal lesions. JAMA 231:1060-1062, 1975.
8. McConnell JD, Peters PC, Lewis SE: Testicular rupture
in blunt scrotal trauma- Review of 15 cases with recent
application of testicular scanning. J Urol 128:309-31 1, 1982.
9. Altaffer LF: Testicular torsion in men. J Urol 123:37-38,
1980.
10. Ransler CW, Allen TD: Torsion of the spermatic cord.
Urol Clin North Am 9:245-250, 1982.
11. Williamson RCN: Torsion of the testis and allied
conditions. Br J Surg 63:465-476, 1976.
12. Rodriguez DD, Rodriguez WC, Rivera JJ, Rodriguez S,
Otero AA Doppler ultrasound versus testicular scanning in
the evaluation of the acute scrotum. J Urol 125:343-346,
1981.
13. Iuchtman M, Zoireff L, Assa J: Doppler flowmeter in the
differential diagnosis of the acute scrotum in children. J Urol
121:221-222, 1979.
14. Nasrallah PF, Manzone D, King LR Falsely negative
Doppler examinations in testicular torsion. J Urol
118:194-195, 1977.
15. Atallah MW, Mazzarino AF, Horton BF: Testicular scan,
diagnosis and followup for torsion of testis. J Urol
118:120-121, 1977.
16. Cattolica EV, Karol JB, Rankin KN, Klein RS: High
testicular salvage rate in torsion of the spermatic cord. J Urol
128:66-68, 1982.
VOL. 81— NUMBER 3— MARCH 1984
193
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access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and^Mnewhat variable INDERAL has
been shown to cause a small increase in serum potassidRconcentration when usee® the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces thflKflBn
any given level of effort by blocking the catecholamine/H8MMb '
systolic blood pressure, and the velocity and extent off"®*
may increase oxygen requirements by increasing left^L
pressure and systolic election period The net DhvfltgjgjBPfel
is usually advantageous and is manifested dunhgigxffrcise^
increased work capacity
In dosages greater than required for beta blockade, INDERAL alsoexerts a quinidine-|
or anesthetic-like membrane action which affects '
cance of the membrane action in the treatment of .
The mechanism of the antimigraine effect of pr|
adrenergic receptors have been demonstrated inf
Beta receptor blockade can be useful in cond
functional changes, sympathetic activity is detrin
situations in which sympathetic stimulation is vital
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved h patients subject to bronchospasm.
Propranolol is not significant! 'yzable,
INDICATIONS AND USAGE, t ^Tension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be useu alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
MAJOR SURGERY; The necessity or desirability of withdrawal of beta-blocking therap
prior to ma|or surgery is controversial It should be noted, however, that the impaired ability <J
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesi j
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of beta
receptor agonists and its effects can be reversed by administration of such agents, e g !
dobutamme or isoproterenol. However, such patients may be subject to protracted sever
hypotension Difficulty in starting and maintaining the heartbeat has also been reported wit ;
beta blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent the api
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes) ( ■]
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be morj
difficult to adjust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidisrr |
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptom j
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function test; |
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bee I
reported in which, after propranolol, the tachycardia was replaced by a severe bradycardi [
requiring a demand pacemaker In one case this resulted after an initial dose of 5 mi J
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with impaire<
hepatic or renal function INDERAL is not indicated for the treatment of hypertensive
emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Patient
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal ma
lead to a return of increased intraocular pressure
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart disease
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as resei
pine .should be closely observed if INDERAL is administered. The added catecholamine
blocking action may produce an excessive reduction of resting sympathetic nervous activit'
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostatic
hypotension
Carcinogenesis, Mutagenesis. Impairment ot Fertility Long-term studies in animals havi
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studies ir
LiOmg/kg/day. there was no evidence of signif ican
lated tumorigenic effects at any of the dosagr
not show any impairment of fertility that wai
DERAL has been shown to be embryotoxic ir
r than the maximum recommended human dose
eqCfSfPWrd weiwamfolled studies in pregnant women INDERAL shoulc
nancy only if the potential benefit justifies the potential risk to the fetus
INDERAL is excreted in human milk. Caution should be exercised wher
ian
s in children have not been established
effects have been mild and transient and haw
nsioi
aynau
Central Nervous Syste,
lassitude, weakness, fatigui
aroestive heart failure; intensification of AV block; hypo
,cS3B'lSLjrpura: ar,enal insufficiency, usually of the
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
eadedness; mental depression manifested by insomnia
"ersible mental depression progressing to catatonia; visua
disturbances, hallucinations; an acute reversible syndrome characterized by disorientation fo :
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, ancj
decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhea;
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with achinc j
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic ,
purpura.
Auto-Immune In extremely rare instances, systemic lupus erythematosus has beer ;
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous reaction!)
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practolol |
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride in £ :
sustained-release capsule for administration once daily If patients are switched from INDERAL 1
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeutic :
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute fo 1
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitration maj
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interval
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 me;
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may be
increased to 120 mg once daily or higher until adequate blood-pressure control is achieved i
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 64(1
mg may be required The time needed for full hypertensive response to a given dosage is.
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized Starting with 80 mg INDERAL LA
once daily, dosage should be gradually increased at three to seven day intervals until optimum
response is obtained Although individual patients may respond at any dosage level, the
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value anc
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few week;
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL LA
once daily. The usual effective dose range is 160-240 mg once daily. The dosage may be
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is no'
obtained within four to six weeks after reaching the maximum dose, INDERAL LA therapj
should be discontinued It may be advisable to withdraw the drug gradually over a period o
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group are toe
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a reqistered trademark of Ayerst Laboratories
8950/284
Nonallergic Bronchospasm je.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTiC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
196
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Evaluation of the Suicidal Adolescent
Patient Admitted to an Urban Hospital
Sophie Pierog, m.d., and Austin Hill, ph.d., jersey city*
Suicide is a frequent cause of death in adolescence , but the
number of suicide gestures exceeds successful suicide. We
reviewed the suicide experience; patients were studied as to
method and lethality of attempt and psychotherapy .
Treatment in a general pediatric/adolescent hospital ward
was safe and efficacious.
Suicide is reported as a frequent
cause of death in adolescence.
Since the number of successful
suicides among adolescents reflects only 0.5 to 1.0 per-
cent of the actual attempts, it is obvious that this
represents a substantial problem in pedi-
atric/adolescent medicine.1 Ravenhorst estimated that
suicidal attempts in an urban population may account
for some 12 percent of all emergency room visits.2
Suicide “gestures” as compared to successful suicides
have been reported at a ratio of 50 to 120 to 1, in-
dicating that this method may be used as a “cry for
help" by the teenager who is not mentally disturbed
but in desperate need for adult (societal) attention.3
Marks, acting on this premise, safely hospitalized her
suicidal adolescents on a general ward to provide a
separation from the stresses in the environment which
triggered the suicidal act.4
At Jersey City Medical Center, we decided that all
adolescents and preadolescents with a history of at-
tempted suicide automatically would be admitted to
the general pediatric/ adolescent service. The purposes
of our year-long study were: to evaluate such patients
as to their ethnic background, family background, and
personal psychopathology and the method and lethali-
ty of the attempt: and to determine the safety and
efficacy of admitting these patients to a general, open
ward service by comparing our data to Marks.4
METHOD
The pediatric/adolescent department at the Jersey
City Medical Center admits patients up to and includ-
ing the age of 15. All adolescents and preadolescents
who came or were brought to the emergency room or
to the outpatient service following a suicide attempt
were admitted to the general pediatric/adolescent ser-
vice. In addition to the care provided by the medical
and nursing staffs, these patients received evaluation
and crisis intervention by the staff clinical psychol-
ogist with consultations by a child psychiatrist as in-
dicated. Suicidal patients were not singled out from
the regular inpatient population and were expected to
participate in all ward activities.
To evaluate the lethality of the suicidal attempt, the
definition of lethality (i.e. the probability that the pa-
tient will attempt suicide in the immediate future) as
described by Scheidman was applied.5
RESULTS
From July, 1979, to July 1, 1980, 1,830 children
were admitted to the children/adolescent sendee of
Jersey City Medical Center which admits children 3.0
‘From the Department of Pediatrics, Jersey City Medical
Center where Dr. Pierog is Director of Pediatrics and Dr. Hill
is a Clinical Psychologist. Correspondence may be addressed
to Dr. Pierog, Jersey City Medical Center, 50 Baldwin Avenue,
Jersey City, NJ 07304.
VOL. 81— NUMBER 3— MARCH 1984
197
TABLE 1
Suicidal Adolescents
Previous
Loss of
Use of
Lives
Patient
Sex
Age
Attempt(s)
Parent*
Ethanol
With/In:
1
M
12.5
3
F
No
Shelter
2
F
14.1
0
F
No
M
3
F
15.11
1
F
F
M and
Step F
4
F
15.3
0
No
F and
Patient
Shelter
5
F
15.9
Many
Both
Foster
Parents
Shelter
6
M
15.5
1
Both
Patient
Shelter
7
M
15.0
0
F
—
M
8
F
15.2
0
No
F
Both
9
F
14.10
3
F
Step F
and
Patient
M and
Step F
10
F
15.6
0
F
Patient
M
11
F
14.11
0
F
No
Shelter
12
F
15.2
0
F
No
M
13
M
16.5
2
F
Patient
Shelter
14
F
13.10
1
F
Patient
M
15
F
15.9
3
No
F and
Patient
Both
16
F
14.1
0
F
F
M
17
F
12.4
0
F
M
Foster
Parents
18
F
14.4
0
F
No
M
19
F
14.7
0
F
No
M
20
F
14.1
0
F
No
M
21
F
7.8
0
F
No
M
22
F
14.8
0
F
M
M
23
F
15.5
2
F
M
Foster
Parent
24
M
15.2
0
Both
Patient
Foster
Parent
25
F
15
0
No
No
Both
26
F
15
1
No
F
Both
27
F
13.10
0
No
Both
Both
28
*F = Father; M =
F
Mother
11.9
0
Both
No
Foster
Parent
to 15. 1 1 years of age. Jersey City Medical Center is a
625-bed, urban hospital which is the residency teach-
ing center for Hudson County. Satellite hospitals in the
county transfer problem patients to the Medical Center
for care.
Twenty-eight adolescents/preadoleseents were ad-
mitted for attempted suicide in that year; 1 adolescent
was 16.5 years of age. Twenty-three patients were
female and 5 patients were male, giving a ratio of 4.6
to 1, female to male. Of the 23 female patients, 1 1 or
48 percent were Hispanic sumamed. The data on the ;
28 patients are presented in Table 1.
The ethnic distribution of the children consisted of
11 black (39 percent), 4 white (14 percent), and 12
Hispanic sumamed (46 percent) adolescents. The de- J
mographie data from the 1970 census of Hudson
County (Jersey City is the major city and county seat)
shows a distribution of population to be 34.5 percent
black, 60 percent white, 42 percent Hispanic, and 1.3
percent other. Ten of 28 patients (7 female and 3 male)
198
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
:ad a history' of previous suicide attempts; 1 had too
lany to recall and the rest had 1 to 3 attempts.
Of 28 patients, 22 had a loss of one or both parents
jy death, divorce, or separation), 6 were living in
helters, and 4 were in foster care. The parent, sur-
ogate parent, the patient, or some combination of
hese had an alcohol problem in 17 cases; 7 of the
hildren had an alcohol problem. Of the female adoles-
ents, 4 or 17 percent were pregnant at the time of
heir attempt.
The most frequent precipitating event was a conflict
idth a parent or parent surrogate (Table 2). These
onflicts most often involved issues of parental or
authority control. The most frequent method used in
he attempt was ingestion of toxic or potentially toxic
ubstances (22 or 79 percent); drugs used included
ispirin, phenobarbital, anticonvulsants, alcohol, and
leaning products. Seven cases of the substance inges-
ion were considered moderate to high lethality, 3 pa-
tents inflicted bodily injury and 3 threatened to jump
)ut the window from 4 to 8 stories (Table 3).
The initial diagnoses of all 28 patients are listed in
Table 4; the most common was adjustment reaction of
idolescents. Twenty-seven or 96 percent were de-
iressed at the time they were interviewed by the
dinical psychologist and all 28 were noted to be angry.
The average stay on the pediatric/adolescent ward was
ess than two weeks and all but 1 of the patients were
discharged to the community with appropriate refer-
TABLE 2
Events Precipitating the Adolescent Suicide Attempt
Reason No.
Parental conflict 15
Parental/caretaker conflict 18
Romantic conflict 6
Personal loss 1
Legal problems 2
Peer problems 1
Not noted 1
TABLE 3
Method of Suicide Attempt and Lethality
No.
Low
Lethality
Mod-
erate High
Pills
18
12
4 2
Threatened to jump out
of window
2
2
Slash wrist/stab self
3
2
1
Alcohol
1
1
Alcohol and pills
2
2
Other chemical ingestion
1
1 .
Combination (window
and slash)
1
1
Total
28
VOL. 81— NUMBER 3— MARCH 1984
rals to after-care facilities. One child was transferred
to the adult inpatient psychiatric unit for longer treat-
ment.
All patients had initial constant nursing observation
for at least four to eight hours. All were treated with
minimal disturbance to the pediatric ward routine and
none of the patients attempted to hurt themselves or
others while on the ward.
DISCUSSION
Verifying Marks's findings, we found that suicidal
adolescent patients adjusted well in a general pediatric
ward, they were effectively controlled, and they were
able to be discharged for outpatient followup.4 None of
our patients was deemed psychotic which also was
consistent with Marks's findings (10 percent of her
patients were considered psychotic). Suicidal activity
appears to be a way of attempting to deal with stress
rather than a reflection of severe mental illness. The
pediatric/ adolescent ward, therefore, is an appropriate
facility to treat the patient, relieving the patient and
family of the stigma often associated with psychiatric
hospitalization. In addition, it was noted that the pres-
ence of the suicidal adolescents in the general pedi-
atric ward was not disruptive to the ongoing function-
ing of that ward. It seldom was necessary to supply
special nursing services for the suicidal adolescents
beyond the observation period of less than four to eight
hours. Though each of the patients was referred for
outpatient psychiatric care on discharge it was not the
attempt of this study to follow up on the compliance
of the patient. The preponderance of female patients
(82 percent) is consistent with previous studies.36 In
our study there seemed to be a disproportionate
number of Hispanic adolescents admitted for suicidal
behavior (46 percent) with a preponderance of His-
panic females. Again, this is consistent with Marks's
finding in that there seemed to be an ethnosexual
mode of expression manifest in their suicidal adoles-
cents. Our findings are striking considering the His-
panic population of Jersey City numbers only 4.2 per-
cent of the 1970 census. Taking into account the
growth of the Hispanic population in the last decade,
the Hispanic population seems to be considerably rep-
TABLE 4
Initial Psychiatric Diagnosis upon Admission:
Patterns of Behavior Dysfunction
Diagnosis No.
Child abuse (targets of abuse by adults) 3
Adjustment reaction of adolescence 8
Runaway reaction 3
Unsocialized aggressive reaction 5
Inadequate personality (borderline) 2
Depressive neurosis 4
Seizure disorder l
Hysterical neurosis l
Group delinquent reaction l
Total 28
199
.-■nted. A noteworthy number (36 percent in our
study) of our suicidal adolescents had admitted to or
were known to have made previous suicide attempts;
in most of the suicide attempts, drugs were used.
Sexual stress factors appear to be a common de-
ninator in predisposing adolescents to suicide at-
tempts. Actual pregnancy or fear of pregnancy ( 1 7 per-
cent in our study) was one such factor; separation from
parental figure(s) is another. Several studies show an
absence of parental figures, notably the fathers in 51
to 72 percent of these youths. Hospitalization of these
youngsters, therefore, would meet the need of the teen-
ager for nurturance and structure. Parental use of al-
cohol also appears to be a common problem; seven
children were involved with alcohol as well.
CONCLUSION
It is clear that the youngsters who attempted suicide
are ordinary youngsters responding in an angry, im-
pulsive fashion to the environmental stresses which
result from parents, peers, drugs, and authorities. A
sensitive family physician or pediatrician should be
able to help the child solve problems by more accept
able means and prevent the morbidity associated with
suicidal attempts. 131
REFERENCES
1. Committee on Adolescence, American Academy of Pedi
atrics: Teenage suicide. Pediatrics 66: 144-146, 1980.
2. Ravenhorst JM: Followup of young women who attemp1
suicide. Dis New Syst 33:792, 1972.
3. McAnamey ER Suicidal behavior of children and youth
Pediatr Clin of NA 22:595-604, 1975.
4. Marks A Negligible risks in the management of the
suicidal teenager on a nonpsychiatric adolescent unit. „
Pediatr 95:305-308, 1979.
5. Scheidman ES: Essays in Self-Destruction. New York,
NY, Science House, 1967.
6. Rohn RD, Sarles RM, Kenny TJ, Reynolds BJ, Heald FP:
Adolescents who attempt suicide. J Pediatr 90:636-638, 1977.
7. Cunningham DG: Are pediatricians qualified to judge
suicide gestures? Pediatrics 67:750, 1981.
200
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
3NLY DALMANE
flurozepom HQ/Roche
IMPROVES SLEEP..]
WITH
COMPLETE
SLEEP LABORATORY
PROOF15...
. £ •
Copyright® 1984 by Roche Producrs Inc
1 'hrs reserved
N All THESE WAYS
■Rapid sleep onset1'6
■Effective for middle-of-the-night
and early-morning awakenings2,5
■ Undiminished efficacy for at
least 28 nights2'4
■Patients usually awake rested
and refreshed7^
■Avoids rebound insomnia after
discontinuation of therapy35,1012
kCaution patients about driving, operating hazardous machinery or drink-
ing alcohol during therapy. Limit dose to 15 mg in elderly or debilitated
jjpatients. Contraindicated during pregnancy.
^ND THE
PREDICTABILITY
rHAT COMES WITH
EXPERIENCE
FOR EFFECTIVE RELIEF OF INSOMNIA
DALMANE
flurazepam HCI/Poche
STANDS APART
15-MG/30-MG
CAPSULES
See next page for
references and summary
of product information
References: 1. Kales J et al : Clin Pharmacol
Ther 12: 691-697, Jul-Aug 1971. 2. Kales A et al:
Clin Pharmacol Ther 18: 356-363, Sep 1975
3. Kales A et al Clin Pharmacol Ther 19:
576-583, May 1976. 4. Kales A et al: Clin Phar-
ma,, I Ther 32:781-788, Dec 1982. 5. Frost JD Jr,
Del.ucchi MR: J Am Genatr Soc 27:541-546, Dec
1979. 6. Kales A, Kales JD: J Clin Pharmacol
3:140-150, Apr 1983. 7. Monti JM: Methods Find
Exp Clin Pharmacol 3: 303-326, May 1981.
8. Greenblatt DJ et al: Sleep 5 (Suppl 1):S 18-S27,
1982 9. Kales A et al: Pharmacology 26:121-137,
1983. 10. Greenblatt DJ, Allen MD, Shader R1
Clin Pharmacol Ther 21: 355-361, Mar 1977.
11. Zimmerman AM: Curr Ther Res 13: 18-22,
Jan 1971. 12. Amrein R et al: Drugs Exp Clin Res
9(1) 85-99, 1983.
Dalmane' @
(lurazepam HCl/Roche
Before prescribing, please consult complete product infor-
mation, a summary of which follows:
Indications: Effective in all types ol insomnia characterized by
difficulty in lulling asleep, frequent nocturnal awakenings and/
or early morning awakening; in patients with recurring insom-
nia or poor sleeping habits; in acute or chronic medical situa-
tions requiring restlul sleep. Objective sleep laboratory data
have shown effectiveness for at least 28 consecutive nights of
administration. Since insomnia is often transient and intermit-
tent, prolonged administration is generally not necessary or rec-
ommended. Repealed therapy should only be undertaken with
appropriate patient evaluation.
Contraindications: Known hypersensitivity to flurazepam HCI;
pregnancy. Benzodiazepines may cause letal damage when
administered during pregnancy. Several studies suggest an
increased risk of congenital malformations associated with ben-
zodiazepine use during the first trimester. Warn patients ol the
potential risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam. Instruct patient to
discontinue drug prior to becoming pregnant. Consider the pos-
sibility ol pregnancy prior to instituting therapy.
Warnings: Caution patients about possible combined effects
with alcohol and other CNS depressants. An additive effect
may occur if alcohol is consumed the day following use lor
nighttime sedation. This potential may exist lor several days
following discontinuation. Caution against hazardous occupa-
tions requiring complete mental alertness (e.5. , operating
machinery, driving). Potential impairment of performance of
such activities may occur the day following ingestion Not rec-
ommended for use in persons under 1 5 years of age. Though
physical and psychological dependence have not been reported
on recommended doses, abrupt discontinuation should be
avoided with gradual tapering of dosage for those patients on
medication lor a prolonged period of time. Use caution in
administering to addiction-prone individuals or those who might
increase dosage.
Precautions: In elderly and debilitated patients, it is recom-
mended that the dosage be limited to 15 mg to reduce risk of
oversedation, dizziness, confusion and/or ataxia. Consider
potential additive effects with other hypnotics or CNS depres-
sants. Employ usual precautions in severely depressed patients,
or in those with latent depression or suicidal tendencies, or in
those with impaired renal or hepatic (unction.
Adverse Reactions: Dizziness, drowsiness, lighlheadedness.
staggering, ataxia and falling have occurred, particularly in
elderly or debilitated patients. Severe sedation, lethargy, dis-
orientation and coma, probably indicative of drug intolerance or
overdosage, have been reported. Also reported: headache,
heartburn, upset stomach, nausea, vomiting, diarrhea, constipa-
tion. Gl pain, nervousness, talkativeness, apprehension, irrita-
bility. weakness, palpitations, chest pains, body and joint pains
and GU complaints. There have also been rare occurrences of
leukopenia, granulocytopenia, sweating, flushes, difficulty in
focusing, blurred vision, burning eyes, faintness, hypotension,
shortness of breath, pruritus, skin rash, dry mouth, bitter taste,
excessive salivation, anorexia, euphoria, depression, slurred
speech, confusion, restlessness, hallucinations, and elevated
SGOT, SGPT. total and direct bilirubins, and alkaline phospha-
tase; and paradoxical reactions, e.5. . excitement, stimulation
and hyperactivity.
Dosage: Individualize lor maximum beneficial effect. Adults :
30 mg usual dosage; 1 5 mg may suffice in some patients.
Elderly or debilitated patients . 15 mg recommended initially
until response is determined.
Supplied: Capsules containing 15 mg or 30 mg flurazepam HCI.
Roche Products Inc.
Manali. Puerto Rico 00701
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“The Doctors’ Company”
A Method of Abdominal
Wound Closure
Ian D. Samson, m.d., Jesse Schulman, m.d., Jack C. Sabo, m.d., William M. Schulman, m.d.,
Lawrence W. Silvers, m.d., lakewood*
A technique for the secure closure of abdominal incisions is
described utilizing mass approximation of tissues by a
continuous , looped , nonabsorbable nylon suture which is shown
to have a low incidence of undesirable sequelae. Ease and speed
of insertion, low cost, and low complication rate make this an
attractive method of abdominal wound closure.
A number of techniques for ab-
dominal wound closure have
been proposed. The rationale for
the use of a method is based on surgical dogma and
traditional teaching rather than on scientific fact or
on an analysis of personal experience. The preferred
method of abdominal wound closure should be: 1 ) uni-
versally applicable, simple, and inexpensive: and 2) ac-
companied by a low incidence of untoward complica-
tions, such as wound disruption, late incisional hernia
formation, discharging sinus with the extrusion of
suture material, and a chronically painful scar.
Since 1977, we have been using a continuous mono-
filament, nonabsorbable suture for abdominal wall
closure. From 1980, stimulated by the excellent results
reported by Jenkins, we have used a looped nylon
suture for this purpose.1
This study is a prospective analysis of our experience
with the latter method, which we believe approximates
the ideal.
PATIENTS AND METHODS
Since February 1980, all patients undergoing
celiotomy had the abdominal incision closed with a
looped nylon suture and were included in the prospec-
tive study. Since the study was terminated in July
1982, an additional 167 patients had their wound
closed using the identical technique but were analyzed
only for wound disruption and early hernia formation.
No escape clause was provided. The study, therefore,
includes patients with fecal contamination of the peri-
toneum, as well as patients with frank intra-adominal
sepsis. Midline incisions were approximated as a mass
closure incorporating both fascia and peritoneum in
a running suture. The suture was constructed of 183
cm of #0 nylon swagged onto an XLH needle to provide
a usable suture length of 91.5 cm. The suture was
prepared by Ethicon for this purpose (Figure 1). In
most cases, a single length of suture was sufficient to
accomplish closure. However, for wounds of ex-
traordinary length, i.e. for the resection of an ab-
dominal aortic aneurysm, it was necessary to use two
or possibly three lengths of suture to obtain closure
without undue tension. An attempt was made to ob-
tain a suture:wound length ratio of a least 3:1 and
preferably 4:1 to achieve a firm but relaxed wound
closure. The initial bite was taken just beyond the apex
of the wound and the needle was passed through the
loop to anchor one end. Successive bites of fascia and
peritoneum were taken at least 1 .5 cm from the wound
edge and 1 to 1.5 cm apart, with only enough tension
to approximate the wound edges. When the peri-
toneum could not be included in the closure for techni-
cal reasons, no special effort was made to do so, and
the fascia alone was approximated. When fascia and
*From Paul Kimball Medical Center and Community Mem-
orial Hospital, Lakewood. Correspondence may be addressed
to Dr. Samson, 5 Prospect Street, Lakewood, NJ 08701.
VOL. 81— NUMBER 3— MARCH 1984
205
Figure 2 — Closure technique.
A '
Figure 1— Looped nylon suture showing apex of loop (A) and
both ends swagged on to XLH needle (B) (Ethicon).
peritoneum were taken together, the peritoneum was
prevented from protruding between the fascial edges.
A simple technique for burying the knot was devised,
thereby preventing extrusion of the cut edges of the
suture through the skin or into the abdominal cavity.
When near completion of the closure, the looped suture
was drawn through the fascia from its superficial to
deep aspects and then one strand of nylon was cut free
from the needle. The second strand then was brought
out through the opposite side from the deep to the
superficial aspects of the fascia and finally returned
from superficial to deep to the fascia. The suture then
was snugged up and tied so that the knot was placed
deep to the fascia. The ends of the suture were left long
and were brought through the last three previously
placed loops with a modified aneurysm needle and
then cut flush (Figures 2 to 5).
Kocher and transverse incisions were closed in one
or two layers. When a two-layer closure was selected,
the deep layer consisted of a continuous 0 Viciyl while
the superficial layers were approximated using the
looped nylon suture in the same manner that was used
for a vertical incision. Single-layer closure for trans-
verse and Kocher incisions was carried out using
identical maneuvers to those used for vertical in-
cisions.
When appropriate, an antibiotic-containing solution
was used to irrigate the peritoneal cavity. On occasion,
when gross contamination was evident, a povidone-
iodine solution was instilled into the subcutaneous
tissue after carefui wound irrigation. In the presence
B
Figure 3 — Closure technique.
of severe infection or contamination, the skin was not
closed. No other form of reinforcing sutures, such as
a retention suture, was used. When drains were re-
quired they always were placed away from the closure
and brought out through separate incisions. In one
instance, a mucous fistula was brought out through
the lower end of the wound. Active colostomies were
brought out through a separate incision as far re-
moved as possible from the wound closure. Primary
maturing of the colostomy was employed frequently.
Each procedure carefully was documented and data
were recorded for age, sex, and complicating factors,
(e.g. cardiac failure, jaundice, respiratory disease,
206
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Figure 4 — Closure technique.
uremia hypoalbuminemia steriods, incisions, re-
operations). Surgical details included the nature of the
procedure (elective or emergent), type of procedure,
and nature of the incision (midline, transverse, para-
median, or Kocher). The degree of contamination was
recorded as clean, potentially contaminated, or frankly
{contaminated. The presence or absence of ascites was
noted. Further details concerning the precise method
of closure, the length of the wound, depth of the fat,
and closure time also were recorded. All wounds were
evaluated at the time of discharge and at six months.
Complications such as evisceration, late hernia forma-
tion, and prolonged wound sepsis were documented.
FINDINGS
In this study, 234 patients were entered: 140 females
and 94 males. Their ages ranged from 16 years to 95
years. The vast majority’of patients (162) were in the
60 to 69 age group and the 70 to 79 age group. Seventy
percent of the procedures were elective while 30 per-
cent were emergent operations. Thirty-nine patients
were classified as thin, with abdominal wall fat
measuring less than 1.5 cm in depth. One hundred
twenty-one were classified as of average build, with
abdominal wall fat of between 1.5 and 3 cm in depth,
while 52 were considered obese, with abdominal wall
fat of greater than 3 cm in depth. Of that last group,
13 were considered massively obese, and had ab-
dominal wall fat measuring more than 6 cm. One hun-
dred twenty-one closures were midline, and 76 were
Koeher incisions. There were 26 transverse incisions
and 3 paramedian incisions. Eighty-eight operations
were considered clean, 109 were potentially con-
taminated, and 33 were frankly contaminated. Ascites
was present in 6 eases. Twenty-nine of the Koeher and
Figure 5 — Closure technique.
transverse incisions were closed with a single-suture
technique while the remainder were closed using a
superficial and a deep layer. There were two wound
dehiscences, both associated with vertical incisions.
No eviscerations occurred. All wounds were healed
soundly at the time of discharge, with the exception
of some that were allowed to heal by secondary inten-
tion. No hernias were encountered at the time of dis-
charge. We followed 172 patients for six months. At
this time there were 2 incisional hernias and 2 pa-
tients had wound sepsis. There were no cases of ex-
truding suture material, and no patient had signifi-
cant complaints concerning his or her wound. An ad-
ditional 167 wounds were closed in the same manner
and were evaluated for healing at the time of discharge:
all were found to be healed soundly.
Very little time was expended in closing the fascial
layers. Vertical incisions measuring less than 24 cm
in length were approximated, in an average of 7.3
TABLE 1
Predisposing Factors
Obesity
51
Frank sepsis
33
Previous operative sears, hernia, and
23
early reoperation
Hypoalbuminemia
17
Pulmonary disease
17
Jaundice
1 1
Uremia
5
Cardiac failure
5
Steroids
3
Others
3
Irradiation
1
VOL. 81— NUMBER 3— MARCH 1984
207
minutes, while those measuring in excess of 31 cm
took 1 1 minutes to close. Transverse and Kocher in-
cisions averaged 18 cm in length and took 7.6 minutes
to close in two layers and 5.8 minutes to close when
a single layer was used. The expeditious closure was
appreciated at the end of long, tedious procedures!
There were 186 classical complicating factors
predisposing to wound failure present. The most com-
monly encountered problems (Table 1) were obesity
(51). frank sepsis (33), previous operative scars, hernia,
and early reoperation (23), hypoalbuminemia (17),
chronic obst motive pulmonary disease (17), and jaun-
dice (11). It is felt that this pattern of complications
probably does not vaiy significantly from that com-
monly seen in everyday surgical practice.
DISCUSSION
The fact that the debate concerning the virtues and
pitfalls of suture materials and techniques is never-
ending serves to notify us that the ideal form of ab-
dominal incision closure has not been determined or,
if it has, we have failed to recognize it. For most, habit,
prejudice, and surgical dogma have come to be as im-
portant as scientific analysis in the selection of a
closure technique.
In any analysis of wound closure techniques, con-
sideration is given to both the material used and the
method of its insertion. With regard to suture material.
Table 2 shows the acceptable classification.
There are two primary methods of suture placement.
The first involves separate approximation of the indi-
vidual layers of the abdominal wall— layered closure.
The second method is that of approximation of all
layers within a single suture— mass closure. In almost
all instances the skin is excluded in mass closure.
However, in cases of wound disruption, mass closure
including all layers of the abdominal wall is commonly
utilized.
Layered closure almost universally is selected for the
closure of oblique and transverse abdominal incisions,
and has its proponents for the closure of vertical in-
cisions as well. The technique of mass closure usually
is employed in vertical wounds, and in the repair of
wound dehiscense, irrespective of the position of the
primary incision.
The mass closure technique has been shown ex-
perimentally to be superior in the early phase of wound
healing, where extrinsic strength is a major consider-
ation.2 This finding has been borne out by clinical
experience.3
Further consideration occasionally is given to
providing additional support to the closure by adding
some form of buttress or retention layer.4 This second-
ary supporting layer rightly should be considered as
an extension of mass closure. It has been recommend-
ed even when formal mass closure has been used.5
However, more frequently it is used to support a
layered closure when an absorbable suture has been
used to approximate the fascia.3 Whether or not reten-
tion sutures add anything of substance to a mass
closure has not been demonstrated adequately. In a
prospective series comparing closures with and
without the addition oi retention sutures, Hubbard
and Rever found a significantly higher rate of de-
hiscense when retentions were used.6
TABLE 2
Suture Material
1 . Nonabsorbable
A. Natural
1. Cotton
2. Silk
B. Synthetic
1. Polyamide (nylon)*
2. Polyester*
3. Polypropylene (prolene)
4. Metallic (thread)*/(staple)
2. Absorbable
A. Natural
1. Catgut
2. Collagen
B. Synthetic
1. Polyglycolie acid
2. Polyglactin*
‘Monofilament or braided
As the advantages of this additional layer are
doubtful at best, it is proposed that the discomfort and
unsightly scarring produced by retention sutures, as
well as the increase in operating time, do not warrant
its usage.
Other factors that apply to the closure concern the
physical changes exerted by differing methods of
suture placement and by the inherent characteristics
of the material per se. In the first instance, knot slip-
page is a function of the suture material. A spectrum
exists that extends from the great security that is
found in a knot placed in wire to a propensity for
loosening and slippage that is found with moistened
plain catgut. In general, one can conclude that the
fewer knots that are required to be placed, the less
likely the closure is to come apart. A continuous suture
technique therefore would have a theoretical advan-
tage over an interrupted one, as there are less knots
to come loose. Other than knot security, the integrity
of the suture material is of considerable significance.
Ideally the material should be nonreactive, retain its
tensile strength throughout the period of maturation
of the suture line, and be totally resorbed. Such a ma-
terial is not available. These characteristics are ap-
proached by the modem absorbables (e.g. polyglactin),
which are relatively nonreactive but undergo pro-
gressive dissolution from the time of insertion, and on
the other hand, by the monofilament nonabsorbables
(e.g. nylon), which are virtually inert, and maintain
their tensile strength but are retained in the body
indefinitely.
Secondly, it would seem that precise fascial approx-
imation is important. In all midline incisions, it is
appropriate to oppose in an accurate fashion the raw
fascial edges, rather than to incorporate fat or peri-
toneum between these edges. Where the mesothelium
becomes interposed between fascia, a weaker sear is
produced, and it has been demonstrated that a
mesothelial to mesothelial scar is less secure than one :
between raw fascial edges.7
A further consideration is the provision for
stretching of the wound in the postoperative phase
due to edema and abdominal distension. Jenkins es-
208
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
tablished an experimental model to calculate the re-
verse of suture length necessary to allow for this
lengthening and to ensure a minimal resulting rise in
tension between the sutures and the tissues.1 The
findings were extrapolated and used in a clinical series
with a dehiscense rate of 0.5 percent. He concluded
that wound disruption due to cutting out of sutures
can be prevented by the use of nonabsorbable continu-
ous sutures placed at 1 cm intervals and a suture:
wound length ratio of 4:1 or more.
A review of the recent literature reveals a number of
studies evaluating a fairly wide spectrum of tech-
niques and suture materials.8 13 The infection rate
varies from 4.1 to 24.8 percent, sinus rate from 0 to
14 percent, dehiscence rate from 0 to 10.2 percent, and
the late hernia rate from 9 to 11.5 percent. The best
figures were obtained using a mass closure with a
continuous nylon suture1 or continuous polyglycolie
acid and polyglactin.9 An outline of the relevant find-
ings is illustrated in Table 3.
The results of the present series compare favorably
with those reported. Our incidence of wound de-
hiscence was 0.7 percent in a totally unseleeted group
of patients, which included an unusually large elderly
population. There were no eases of late wound infec-
tions and no wound sinuses. The late hernia rate was
less than 1 percent.
Irrespective of the technique used for wound closure,
the final objective should be the same: to produce a
soundly healed, comfortable wound with no
predisposition to early or late herniation, and a wound
dehiscence rate that approaches zero. Secondary con
siderations, such as the cost of material and speed of
closure, should be borne in mind but obviously are not
major determinants in the final outcome. Of prime
importance, however, is the need for the technique in
question to be reproducible and attainable by both
novice and expert alike.
CONCLUSIONS
A number of tenets have surfaced from experimen-
tal data and from the reported and present series. The
first is that mass closure is preferable to layered
closure. The second is that the interrupted suture
technique is no better than the continuous one. This
being the case, the continuous suture technique is
preferable because it is more expeditious. Finally, but-
tressing or retention sutures are not required.
The closure method outlined in our study has an
acceptably low dehiscence and hernia rate, and is not
TABLE 3
Review of the Literature*
Reference
Suture
L
M
c
I
R
IN
S/IN
D
H
T
Comments
Goligher et al.3
Catgut
X
X
X
9.3
1.9
10.2
3.7
13.9
Reinforced,
paramedian
ant. layer
interrupt
Catgut
X
X
X
15.4
10.6
0.96
3.8
4.8
Wire
X
X
10.2
4.6
0.93
0
0.93
Jones
Irvin et al.'1
Polyglycolie
X
X
9.6
5.8
3.8
9.6
Polyglactin
X
X
7.7
—
5.8
5.8
Polypropyl
X
X
14.0
3.5
5.3
8.8
Jenkins'
Looped
Nylon
X
X
0.07
0.0007
Vertical only
Leaper et al.8
Nylon
X
X
20.3
0.86
5.2
6
Chromic-
peritoneum
Wire
X
X
21.7
0.83
8
8.8
Jones
Polyglyctin
X
X
24.8
0
5.1
5.1
Jones
Sloop9
Polyglycolie
X
X
0
0
0
0
0
Transverse
Polyglactin
2 layers
Bucknall and
Nylon
X
X
21.4
9.4
0.94
3.8
4.8
Vertical
Ellis'0
Polyglactin
X
X
1 1.5
0.96
1 1.5
12.5
only 40 percent
Infections
developed
sinuses
Corman et al.12
Nylon
X
X
4.1
12.2
0
8.9
8.9
Bowel surgery
Polypropyl
X
X
9.4
5.7
1.9
4.4
6.3
Polyglactin
X
X
10.2
0
0
0
0
Samson et al.
Nylon
X
X
0.5
1
Richards et al.'3
Polypropyl
X
X
X
2
2
Polyglycolie
X
X
X
0.9
0.5
(L) Layered, (M) Mass, (C) Continuous, (I) Interrupted, (R) Retention, (IN) Infection, (S/IN) Sinus and/or Infection,
(D) Dehiscence, (H) Hernia, (T) Total Complications.
"Complications expressed in percentages.
VOL. 81— NUMBER 3— MARCH 1984
209
i ompanied by significant morbidity, such as painful
or infected wounds with sinuses. Furthermore, it is
exceptionally inexpensive in terms of materials and
closure time is rapid. Our findings support the excel-
lent results reported by Jenkins.1 We are encouraged
by this analysis to persist with this closure method,
and recommend it to others for their consideration.
REFERENCES
1. Jenkins TPN: The burst abdominal wound: A mechan-
ical approach. Br J Surg 63:873-876, 1976.
2. Dudley HAF: Layered and mass closure of the abdominal
wall: A theoretical and experimental analysis. Br J Surg
57:664-667, 1970.
3. Goligher JC, Irvin TT, Johnston D, DeDombal FT, Hill GL,
Horrocks JC: A controlled clinical trial of three methods of
closure of laparotomy wounds. Br J Surg 62:823-829, 1975.
4. Old WL Jr, Stokes T: Preventing disruption of abdominal
wounds. South Med J 72:545-550, 1979.
5. Ponka JF: Hernias oj the Abdominal Wall. Philadelphia,
PA, W.B. Saunders Co., 1980, p. 356.
6. Hubbard TB Jr, Rever WB Jr Retention sutures in the
closure of abdominal incisions. Am J Surg 124:378-380, 1972.
7. Myers B, Rightor M, Donovan W: An experimental model
in the rat to evaluate technical factors. Arch Surg 1
116:463-465, 1981.
8. Leaper DJ, Pollack AV, Evans M: Abdominal wound :
closure: A trial of nylon polyglycolic acid and steel sutures. Br
J Surg 64:603-606,1977.' I
9. Sloop FID: Running synthetic absorbable suture in ab-
dominal wound closure. Am J Surg 141: 572-573, 1981.
10. Bueknall TE, Ellis H: Abdominal wound closure — a
comparison of monofilament nylon and polyglycolic acid. Sur-
gery 89:672-677, 1981.
11. Irvin TT, Koffman CG, Duthie HL: Layer closure of
laparotomy wounds with absorable and nonabsorbable
suture materials. Br J Surg 63:793-796, 1976.
12. Corman ML, Veidenheimer MC, Coller JA: Controlled
clinical trial of three suture materials for abdominal wall
closure after bowel operations. Am J Surg 141:510-513, 1981.
13. Richards PC, Balch CM, Aldrete JS: Abdominal wound
closure— a randomized prospective study of 571 patients
comparing continuous v interrupted suture techniques. Ann
Surg 197:238-243, 1983.
!
THE JOUFdMAL OF THE MEDICAL SOCIETY OF NEW JERSEY
210
Case Report: Aneurysm of the Descending
Thoracic Aorta
Shashi K. Agarwal, m.d., Jacob I. Haft, m.d., Michael Bachik, m.d., Newark*
The detection of a descending thoracic aortic aneurysm by
M-mode echocardiography is an unreported phenomenon.
Confirmation by cross-sectional echocardiography illustrates the
value of noninvasive techniques in the study of the descending
thoracic aorta.
Cross-sectional echocardiogra-
phy provides a noninvasive vis-
ualization of the entire aortic
root12 and has allowed recognition of disease of this
great vessel.35 Using contrast echocardiography, Mintz
et al. have shown that the descending thoracic aorta
easily can be seen in the parasternal long and short
axis views.6 We recently recognized a large aneuiysm
of the descending thoracic aorta by cross-sectional
echocardiography. Unusual M-mode echocardio-
graphic findings also were observed.
CASE REPORT
The patient was a 76-year-old white female who was
admitted to Saint Michael’s Medical Center, Newark,
forevaluation of shortness of breath. Associated symp-
toms included cough with yellowish expectoration and
fever with chills. Since the chest roentgenogram re-
vealed no parenchymal lung infiltrates (mediastinal
widening was noted), a diagnosis of upper respiratory
tract infection was made (Figure 1). The patient was
known to have hypertension for 20 years. Two months
prior to this admission, she was hospitalized elsewhere
with interscapular pain and diaphoresis. A widened
mediastinum was noticed on the chest . roentgeno-
gram. Angiography was performed and a thoracic
aortic aneurysm was diagnosed (Figure 2).
The recent admission offered a unique opportunity
to evaluate the use of two-dimensional echocardi-
ography in visualizing aneurysms of the descending
thoracic aorta. In the parasternal long axis view (Fig-
ure 3), a large pulsatile echo-free space with a diameter
of 45 mm was noted. On gradually sliding the trans-
ducer to a lower parasternal position, the descending
aorta could be visualized lengthwise, clearly demon-
strating the aneurysmal dilatation (Figure 4). A double
posterior aortic wall also could be seen in this view,
confirming the angiographic findings of an associated
type III dissection. In the apical four-chamber view, the
aneurysm could be visualized just behind the left
atrium by gently rocking the transducer medial to
lateral. An M-mode echocardiogram revealed an echo-
free space behind the left atrium that expanded just
behind the atrio-ventricular groove (on sweeping), also
reflecting the descending aorta and its aneurysm (Fig-
ure 5).
DISCUSSION
Thoracic aortic aneurysms usually exhibit pro-
gressive enlargement and pose the danger of a
catastrophic complication such as rupture.7 Further,
they may cause compression of adjacent structures
resulting in considerable morbidity. Since surgical in-
*From Saint Michael's Medical Center, Newark. Cor-
respondence may be addressed to Dr. Agarwal, Department
of Cardiology, Saint Michael’s Medical Center, 306 High
Street, Newark, NJ 07102.
VOL. 81— NUMBER 3— MARCH 1984
211
Figure 1— PA chest roentgenogram revealing no parenchymal
lung infiltrates (mediastinal widening was noted); diagnosis
of upper respiratoiy tract infection was made.
tervention is useful, early diagnosis is of major import-
ance in their management.8 Although a chest
roentgenogram may be suggestive, reliable diagnosis
usually mandates aortography. Two-dimensional
echocardiography, by providing spatial orientation,
may afford a simple noninvasive alternative.
Demonstration of the descending thoracic aorta by
cross-sectional echocardiography has helped in the
diagnosis of aneurysm,6 patent ductus arteriosus9 and
differentiation of pleural from pericardial effusion.10
Usually, it is seen best in the long axis view as a
pulsatile circular echo-free space posteriosuperior to
the AV groove: it measures 10 ± 1.4 mm/m2 in
diameter at this level.6 In short axis view, it can be seen
directly behind the left ventricle (LVj posterior wall or
just posterior to the bifurcation of the pulmonic artery.
This ease illustrates that in some patients a low para-
sternal long axis view may visualize the whole descend-
ing thoracic aorta lengthwise and may be superior for
recognizing abnormalities of this segment (Figure 4).
1 he large aortic aneuiysm in our patient also was seen
in the apical four-chamber view just behind and lateral
to the left atrium.
1 he demonstration of the aortic aneurysm on M-
mode echocardiography was unusual in our patient.
An echo-free space behind the left atrium sometimes
is recorded and has been attributed to the common
pulmonary vein,11 coronary sinus in total anomalous
pulmonaiy venous drainage,12 pleural effusion,13 or
Figure 2— Retrograde aortic angiography. The arrow shows
the aneurysmal dilatation.
Figure 3— A cross-sectional echocardiogram; parasternal long
axis view. The aortic aneurysm (arrow) is seen just behind
the AV groove. AO = aortic root; MV=mitral valve; LA=left
atrium.
pericardial effusion.14 Contrast echocardiography has
revealed that the normal descending aorta often will
appear as an abnormal echo behind the left atrium.15
The demonstration of an increase in size of the echo-
free space on sweeping from the left atrium (LA) to the
mitral value level on the M-mode echocardiogram in
our patient probably reflects the descending thoracic
212
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
aneuiysm (arrow) is visualized.
Figure 5 — M-mode echocardiogram; aorta to mitral valve
sweep. Note the increase in size of the echo-free space behind
the pericardium. LA=left atrium; DA= descending aorta
MV=mitral value; ANEU= aneurysm.
aorta and its aneurysmal dilatation. Close observation
reveals systolic expansion.
CONCLUSION
Our case report illustrates the potential use of eross-
seetional echocardiography in the assessment of pa-
tients suspected of having thoracic aortic aneurysm
and, in selected cases, reliably may be substituted for
conventional retrograde angiography. Unusual M-
mode echocardiographic findings also are described.
REFERENCES
1. Seward JB, Tajik AJ: Two-dimensional echocardi-
ography. Med Clin North Am 64:177-203, 1980.
2. Kotler MN, Mintz GS, Segal BS, et al.: Clinical use of two-
dimensional echocardiography. Am J Cardiol 45:1061-1082,
1980.
3. DeMaria AN, Bommer W, Newman A, et al.: Identification
and localization of aneurysms of the ascending aorta.
Circulation 59:755-761, 1979.
4. Matsumoto M, Matsuo H, O’Hara T, et al.: A two-
dimensional echocardiographic approach to dissecting
aneurysms of the aorta to prevent false positive diagnosis.
Radiology 127:491-499, 1978.
5. Weyman AE, Caldwell RL, Hurwitz RA, et al.: Cross-sec-
tional echocardiographic detection of aortic obstruction. 2.
Coarctation of the aorta. Circulation 57:498-502, 1978.
6. Mintz GS, Kotler MN, Segal BL, et al.: Two-dimensional
echocardiographic recognition of the descending aorta. Am
J Cardiol 44:232-238, 1979.
7. Joyce JW, Fairbaim JF, Kincaid OW, et al.: Aneurysms
of the thoracic aorta— a clinical study with special reference
to prognosis. Circulation 29:176-181, 1964.
8. Symbas PN: Treatment of thoracic surgical aortic dis-
eases, in Lindsay J Jr, Hurst JW (eds): The Aorta. New York,
NY, Grune and Stratton, 1979, p. 259.
9. Sahn DJ, Allen DHD: Real-time cross-sectional
echocardiographic imaging and measurement of the patent
ductus arteriosus in infants and children. Circulation
58:343-354, 1978.
10. Haaz WS, Mintz GS, Kotler MN, et al.: Two-dimensional
echocardiographic recognition of the descending thoracic
aorta Value in differentiating pericardial from pleural ef-
fusion. Am J Cardiol 46:739-743, 1980.
1 1 . Osmond GM, Ruttenberg HD, Bessinger FB, et al.:
Echocardiographic features of total anomalous venous con-
nection to the coronary sinus. Am J Cardiol 41:597-601,
1978.
12. Aziz KV, Paul MH, Barati S, et al.: Echocardiographic
features of total anomalous pulmonary venous drainage into
the coronary sinus. Am J Cardiol 42:108-114, 1978.
13. Kotler MN, Segal BL, Mintz GS, et al.: Pitfalls and limi-
tations of M-mode echocardiography. Am J Cardiol
42:108-114, 1978.
14. Green DA, Kleid JJ, Narder S: Unusual echocardio-
graphic manifestation of pericardial effusion. Am J Cardiol
39:112-115, 1977.
15. Goh TH, Venables AW: M-mode echocardiogram and
abnormal structures behind the left atrium. Am J Cardiol
44:575, 1979.
VOL. 81— NUMBER 3— MARCH 1984
213
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets —
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING
CAPSULES
Ayerst
The appearance ol
INDERAL LA
capsules is a registered
trademark ol
Ayerst L aboratories.
ONCE-DAILY
JUST ONCE EACH DAY fjMf>C'Dilf ® f A
FOR SIMPLIFIED CORE l*WC L/1
THERAPY IN ANGINA (PROPRANOLOL HCI)
LONG ACTING
CAPSULES
gas
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INOERAL " LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules,
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80. 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs tor the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate ol absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it read|usts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients. " >
In angina pectoris, propranolol generally reduces the oxygen , requirement of the heart at
any given level of effort by blocking the catecholamine nducuti increases tr the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic-
pressure and systolic election period The net physiologic effect of beta-.adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset o' pain and
increased work capacity.
In dosages greater than required for beta blockade. INDERAL also exerts a quinidine-like
or anesthetic-like membrane action which affects the cardiac action Dotentia Jlga. signifi-
cance of the membrane action in the treatment of^rrhythmias is uncertain
The mechanism of the antimigraine effect ot propranolol has not been established. Beta-
adrenergic receptors have been demonstrated in the mat vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital Fof exampleTTn parents wffi“S'everely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients sub|ect to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block: 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therap
prior to maior surgery is controversial. It should be noted, however, that the impaired ability c
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesi.
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of beta
receptor agonists and its effects can be reversed by administration of such agents, e g
dobutamine or isoproterenol. However, such patients may be subject to protracted seven)
hypotension Difficulty in starting and maintaining the heartbeat has also been reported with
b©ts blockers
DIABETES AND HYPOGLYCEMIA; Beta-adrenergic blockade may prevent the ap
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes) o
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be mori
difficult to adjust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidism
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptom;
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function tests
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have beerl
reported in which, after propranolol, the tachycardia was replaced by a severe bradycardir
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 mg
propranolol.
PRECAUTIONS. General Propranolol should be used with caution in patients with impairec
hepatic or renal function. INDERAL is not indicated tor the treatment of hypertensive
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Patients
should be told that INDERAL may interfere with the glaucoma screening test. Withdrawal may
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart disease,
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS. Patients receiving catecholamine-depleting drugs such as reser-
pine should be closely observed if INDERAL is administered. The added catecholamine-
blocking action may produce an excessive reduction of resting sympathetic nervous activity
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostatic
hypotension.
Carcinogenesis. Mutagenesis, Impairment of Fertility. Long-term studies in animals have
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studies in
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of significant
drug-induced ioxtcity There were no drug-related tumorigenic effects at any of the dosage
levels. Reproductive studies in animals did not show any impairment of fertility that was
attributable to the drug
Pregnancy Pregnancy Category "C INDERAL has been shown to be embryotoxic in
animal studies at doses about 10 times greater than the maximum recommended human dose
There are no adequate and weft-controlled studies in pregnant women INDERAL should
be used during pregnancy only if the potential benefit justifies the potential risk to the fetus
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercised when
INDERAL is acf»tt)stered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and have
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive heart failure; intensification of AV block, hypo-
tension; paresthesia of hands; thrombocytopenic purpura arterial insufficiency, usually of the
Raynaud type
Central Nervous System, lightheadedness; mental depression manifested by insomnia,
lassitude, weakness, fatigue, reversible mental depression progressing to catatonia; visual
disturbances, hallucinations, an acute reversible syndrome characterized by disorientation for
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, and
decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhea,
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with aching
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has been
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo-
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous reactions
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practolol)
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride in a
sustained-release capsule for administration once daily. If patients are switched from INDERAL
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeutic
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute for
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitration may
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interval
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 mg
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may be
increased to 120 mg once daily or higher until adequate blood-pressure control is achieved.
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage of 640
mg may be required The time needed for full hypertensive response to a given dosage is
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized Starting with 80 mg INDERAL LA
once daily, dosage should be gradually increased at three to seven day intervals until optimum
response is obtained. Although individual patients may respond at any dosage level, the
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value and
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few weeks
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL LA
once daily. The usual effective dose range is 160-240 mg once daily. The dosage may be
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is not
obtained within four to six weeks after reaching the maximum dose, INDERAL LA therapy
should be discontinued. It may be advisable to withdraw the drug gradually over a period of
several weeks.
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group are too
limited to permit adequate directions for use.
*The appearance of INDERAL LA, capsules is a registered trademark of Ayerst Laboratories.
8833/384
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
216
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Case Report: Radiographic Findings
In Pseudomembranous Colitis
Robert S. Altin, m.d., long branch*
Pseudomembranous colitis , an uncommon disorder related to
antibiotics , infection , and debilitating conditions , is
characterized by a friable, adherent pseudomembrane overlying
an edematous and ulcerated mucosa . Radiologic findings in six
cases included colonic dilatation and irregularity of the bowel
margin (thumbprinting).
Pseudomembranous colitis often
is a complication of antibiotic
therapy, especially clindamy-
cin.1 It also occurs in debilitated patients. The mucosal
surface is lined with pseudomembrane, which may be
either extensive or in isolated plaques.2
Between August 1979 and September 1981, six pa-
tients had the diagnosis of pseudomembranous colitis
made by colonoscopy, autopsy, or surgical specimen.
Plain film findings are reviewed in all patients; barium
enema was performed in one patient shortly before
pseudomembranous colitis was diagnosed.
CASE REPORTS
Case 1: A 71 -year-old female presented with ab-
dominal pain and rectal bleeding. Sigmoid biopsy on
October 4, 1978, showed pseudomembranous colitis
and chronic active colitis. Upper gastrointestinal and
small-bowel series one week earlier were negative,
i Plain film showed thumbprinting of the sigmoid colon
i (Figure 1). The patient was receiving gentamycin and
Cleocin™. Stool culture was negative.
Case 2: A 76-year-old male presented with diarrhea
on September 1, 1981. He had sigmoid resection for
carcinoma and received Mefoxinr' postoperatively.
I Stool was positive for Clostridium difficile toxin on
September 4, 1981; sigmoid biopsy showed
pseudomembranous colitis on September 11, 1981.
Plain film examination showed thumbprinting of the
transverse colon (Figure 3) in comparison to earlier
normal transverse colon (Figure 2).
Case 3: A 96-year-old male had resection of a
sigmoid carcinoma One month later he presented
with diarrhea and was receiving ampicillin. Plain film
of the abdomen was not grossly abnormal, but showed
subtle thumbprinting of the descending colon.
Sigmoid biopsy showed pseudomembranous colitis.
Stool culture was negative.
Case 4: An 80-year-old female with a lower
gastrointestinal bleeding came to the emergency room.
Plain film of the abdomen showed distention of small
and large bowel. She became hypotensive and died the
same day. Autopsy revealed pseudomembranous co-
litis. No antibiotic administration was known.
Case 5: A 74-year-old male complained of rectal
bleeding. No antibiotics were administered. Barium
enema revealed thumbprinting of the descending and
sigmoid colon and distention of the transverse and
right colon, thought to be typical of ischemic or other
colitis. (Figures 4 and 5). Sigmoid resection showed
*Dr. Altin is a Resident, Department of Radiology, Monmouth
Medical Center. Correspondence may be addressed to Dr.
Altin, Monmouth Medical Center, 300 Second Avenue, Long
Branch, NJ 07740.
VOL. 81— NUMBER 3— MARCH 1984
217
Figure 1— Plain film of the abdomen (case report 1) demon-
strates gas within the sigmoid colon (arrowheads). The bowel
margin is irregular and shows the broad-based indentations
known as thumbprinting.
Figure 2— Plain film of the abdomen (case report 2) shortly
before sigmoid resections for carcinoma of the colon. Gas is
present within the transverse colon (arrowheads) in a normal
pattern. The haustral markings are small and smooth (arrow).
Figure 3 — A plain film of the abdomen (case report 3) one
month after sigmoid resection. Diarrhea was present about
one week. Gas in the transverse colon (arrowheads) demon-
strates the large smooth indentations of the colonic margin
known as thumbprinting (arrow).
Figure 4— Barium enema (case report 5) performed for rectal
bleeding. Closeup of the sigmoid colon shows multiple
smooth filling defects of the bowel wall (arrowheads). These
are caused by bowel wall edema and represent thumb-
printing.
Figure 5 — Postevacuation film of the same patient demon-
strates irregular mucosa in the sigmoid colon (arrowheads)
caused by edema and thickening of the bowel wall.
pseudomembranous colitis. Culture revealed
Escherichia coli, enterococcus, Klebsiella pneu-
moniae, and Bacteroides fragilis.
Case 6: After a right hemicolectomy for carcinoma,
cefoxitin was administered. Diarrhea was persistent
postoperatively. Plain films of the abdomen showed
very slight distention of the colon. Biopsy of the splenic
flexure revealed pseudomembranous colitis. Stool cul-
ture was positive for Clostridium difficile.
DISCUSSION
Plain film findings of pseudomembranous colitis in-
clude distention of the small and large bowel, usually
colon, thickening of the wall of the colon with wide
transverse bands, and thumbprinting.3
The small bowel is normally 2 to 3 cm in diameter.
Enlargement beyond this size indicates dilatation;
however, change in caliber from one portion of the
218
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ibowel to another, or change over time, is a better in-
dicator. The colon can vaiy widely in size. Five cm is
about average, and 10 cm is quite dilated, but change
in caliber again is a better indicator of local dilatation.
Thickening of the bowel wall secondary to edema
sometimes will cause separation of loops of bowel.
Thumbprinting is a descriptive term given to the
[smooth indentation of bowel caused by submucosal
edema appearing much like a thumb was pressed
!against the bowel wall. In the colon the appearance is
i that of exaggerated haustral markings. Barium enema
can show a thin irregular filling defect adjacent to the
:mucosa which is described as a shaggy pseudomem-
brane. Projection of barium outside the mucosal
margin indicates ulceration.
i Less frequently, pneumatosis is seen (17 percent), as
well as toxic megacolon (10 percent). Roentgenograms
are negative in 10 percent as well.2 Pneumatosis (air
'in the wall of the bowel) usually is seen easily, with a
lucent strip of air paralleling the bowel. Toxic mega-
colon often involves the transverse colon, and is dilated
greater than 10 cm in diameter.
Three of our six cases had resection of colon
carcinomas shortly before pseudomembranous colitis
was diagnosed. All had received antibiotics and pres-
ented with diarrhea Evidence of Clostridium difficile
was found in two cases. Radiologic plain film findings
were subtle. One patient showed slight dilatation of the
colon, one patient showed questionable thumb-
printing of the descending colon, and the third patient
showed thumbprinting of the transverse colon. The
striking pattern is that of a recently traumatized bowel
in an elderly patient, antibiotic administration, and
ivague radiologic findings.
Our other three cases all presented with rectal bleed-
ing. None were postoperative. One case received anti-
biotics. Stool culture in case 5 showed several species,
but Clostridium difficile was not present. Gross dilata-
tion of small and large bowel was present in case 4
patient, who died shortly after admission secondary to
gastrointestinal bleeding. The other two patients had
distinct thumbprinting. Barium enema on case 5 pa-
tient showed a classical colitis, although pseudomem-
brane was not definitely seen.
Pseudomembranous colitis frequently is a complica-
tion of antibiotic therapy. Early reports implicated
clindamycin, but many others have been added to the
list, including tetracycline, chloramphenicol, penicillin,
ampicillin, and lincomycin.1 Clinical features include
diarrhea, usually without gross blood, pain, distention,
and fever. Morbidity and mortality are considerable.
Prompt diagnosis is important so that the offending
antibiotic can be stopped and vancomycin can be
started. In 1978, Bartlett demonstrated Clostridium
difficile as the cause in antibiotic-related pseudomem-
branous colitis, and vancomycin the specific treat-
ment.5
In the absence of antibiotics, pseudomembranous
colitis has been recognized as a complication of sur-
gery, debilitating disease, bowel obstruction,
hypotensive or other focal hypoperfusion, uremia or
staphylococcal overgrowth.1 Small bowel as well as
colon can be affected. Edema and thickened mucosa
are present and pseudomembrane is found.2
SUMMARY
Radiologic findings in our six patients ranged from
a barium enema diagnostic of colitis to two patients
with only minor findings. Only one patient had a
barium enema by which the diagnosis was suggested
by the radiology department. Thumbprinting (smooth
marginal irregularity secondaiy to bowel wall edema)
was seen in two patients, and was subtle enough in
the third to be of questionable significance non-
specific dilatation was seen in one patient, and slight
colonic dilatation (shortly postoperative) was noted in
another.
A high degree of suspicion is needed to suggest the
diagnosis of pseudomembranous colitis. Plain film
findings often are subtle. Clinical correlation by the
referring physician is critical to rapid diagnosis and
treatment. Since many of the patients are debilitated,
prompt action may help reduce the high mortality of
this disease.
Barium enema is of limited usefulness. It can be
dangerous if the colon is dilated and rarely demon-
strates a pseudomembrane. Sigmoidoscopy or co-
lonoscopy usually is diagnostic.
REFERENCES
1 . Stanley RJ, et al.: The spectrum of radiographic findings
in antiobiotic-related pseudomembranous colitis. Radiology
111:519-524, 1974.
2. Tully TE, Feinberg SB: Those other types of enterocolitis.
Am J Radiol 121:291-299, 1974.
3. Stanley RJ, et al.: Plain film findings in severe
pseudomembranous colitis. Radiology 118:7-11, 1976.
4. Tully TE, Feinberg SB: A reappearance of antibiotic-in-
duced pseudomembranous colitis. Radiology 110:563-567,
1974.
5. Bartlett JG, Gorbach SL: Antibiotie-associated
pseudomembranous colitis due to toxin-producing elostridia
N Engl J Med 298:531:538, 1978.
6. Schapiro RL, Newman A: Acute enterocolitis. Radiology
108:263-538, 1978.
VOL. 81— NUMBER 3— MARCH 1984
219
r>
$$
^ HPS a democratic torum
The AMA Pr<^fwtth your colleagues
Where you. al° 9 can raise and
across the country consensus and
argue ,ssues’ aMA policy >s then
iormulate po\\ actions on is-
translated int P r practice.
sues that a«ec2°^ne stays active
Making sure more good
^
ama.
To Join, or state medical
Contact your . “U"iv sion of Member-
society or 'NrteMD'hDearborn Street.
shi^M^o sN ^0eoa,r call collect,
Chicago, l"'no,b
(312)751-6196.
AMA
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/omen as membei nnaoing AMA pro)-
anTzed medicine. O^90«ortS by
lets and concentrate^ ^
i0unty, state an .nJJeased the leach
a ve s'9n,1icar membership ot women
rship role and strengthening
■\ organized me )n rnedicine
he voice ot wo & participa-
nrouglt ®ncou'^0od reason why
/T'/ yo '
ociety or ^M° h Dearborn Street,
h^nS --rcal- collect,
Chicago, 1'' cois
312) 751-6196-
References:
1 . Stone PH Turi ZG, Muller JE Efficacy of nifedipine therapy for refractory angina
pectoris Am Heart J 104:672-681, September 1982.
2. Antman E, Muller J, Goldberg S, et al: Nifedipine therapy for coronary-artery
spasm: Experience in 127 patients. N Engl J Med 302:1269-1273, June 5, 1980.
BRIEF SUMMARY
PROCARDIA ” (nifedipine) CAPSULES For Oral Us
INDICATIONS AND USAGE: I. Vasospastic Angina: PROCARDIA (nifedipine) is indicated for th
management of vasospastic angina confirmed by any of the following criteria 1) classical patter
of angina at rest accompanied by ST segment elevation, 2) angina or coronary artery spasm pro
voked by ergonovine, or 3) angiographically demonstrated coronary artery spasm In those patient
who have had angiography, the presence of significant fixed obstructive disease is not incompatibl
with the diagnosis of vasospastic angina, provided that the above criteria are satisfied PROCARDI/
may also be used where the clinical presentation suggests a possible vasospastic component bu
where vasospasm has not been confirmed, eg. where pain has a variable threshold on exertion o
in unstable angina where electrocardiographic findings are compatible with intermittent vaso
spasm, or when angina is refractory to nitrates and/or adequate doses of beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated to
the management of chronic stable angina (effort-associated angina) without evidence of vasospasn
in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrate
or who cannot tolerate those agents.
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controllei
trials of up to eight weeks duration in reducing angina frequency and increasing exercise tolerance
but confirmation of sustained effectiveness and evaluation of long-lerm safety in those patients ar
incomplete
Controlled studies in small numbers of patients suggest concomitant use of PROCARDIA anr
beta blocking agents may be beneficial in patients with chronic stable angina, but available infor
mation is not sufficient to predict with confidence the effects of concurrent treatment, especially ir
patients with compromised left ventricular function or cardiac conduction abnormalities. When in
traducing such concomitant therapy, care must be taken to monitor blood pressure closely since
severe hypotension can occur from the combined effects of the drugs (See Warnings.)
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect o
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol-
erated hypotension These responses have usually occurred during initial titration or at the time oi
subsequent upward dosage adjustment, and may be more likely in patients on concomitant beta
blockers.
Severe hypotension and/or increased fluid volume requirements have been reported in patients
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypass
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to be
due to the combination ot PROCARDIA and a beta blocker, but the possibility that it may occur with
PROCARDIA alone, with low doses of fentanyl, in other surgical procedures, or with other narcotic
analgesics cannot be ruled out In PROCARDIA treated patients where surgery using high dose
fentanyl anesthesia is contemplated , the physician should be aware of these potential problems and
if the patient's condition permits, sufficient time (at least 36 hours) should be allowed for
PROCARDIA to be washed out of the body prior to surgery
Increased Angina: Occasional patients have developed well documented increased frequency, du-
ration or severity of angina on starting PROCARDIA or at the time of dosage increases The mech-
anism of this response is not established but could result from decreased coronary perfusion
associated with decreased diastolic pressure with increased heart rate, or from increased demand
resulting from increased heart rate alone
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with-
drawal syndrome with increased angina, probably related to increased sensitivity to catechol-
amines. Initiation of PROCARDIA treatment will not prevent this occurrence and might be expected
to exacerbate it by provoking reflex catecholamine release. There have been occasional reports of
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation It is important
to taper beta blockers if possible, rather than stopping them abruptly before beginning
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed heart
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater risk for
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascular
resistance, careful monitoring of blood pressure during the initial administration and titration
of PROCARDIA is suggested Close observation is especially recommended for patients already
taking medications that.are known to lower blood pressure (See Warnings )
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso-
dilation and not due to left ventricular dysfunction , occurs in about one in ten patients treated with
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diuretic
therapy With patients whose angina is complicated by congestive heart failure, care should be taken
to differentiate this peripheral edema from the effects of increasing left ventricular dysfunction
Drug interactions: Beta-adrenergic blocking agents (See Indications and Warnings.) Experience
in over 1400 patients in a non-comparative clinical trial has shown that concomitant administration
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasional
literature reports suggesting that the combination may increase the likelihood of congestive heart
failure, severe hypotension or exacerbation of angina
Long-acting nitrates PROCARDIA may be safely co-admmistered with nitrates, but there have
been no controlled studies to evaluate the antiangmal effectiveness of this combination
Digitalis. Administration of PROCARDIA with digoxin increased digoxin levels in nine of twelve
normal volunteers The average increase was 45%. Another investigator found no increase in di-
goxin levels in thirteen patients with coronary artery disease In an uncontrolled study of over two
hundred patients with congestive heart failure during which digoxin blood levels were not meas-
ured, digitalis toxicity was not observed Since there have been isolated reports of patients with
elevated digoxin levels, it is recommended that digoxin levels be monitored when initiating, ad|ust-
mg, and discontinuing PROCARDIA to avoid possible over- or under-digitalization
Carcinogenesis, mutagenesis, impairment of fertility When given to rats prior to mating, nife-
dipine caused reduced fertility at a dose approximately 30 times the maximum recommended hu-
man dose
Pregnancy: Category C Please see full prescribing information with reference to teratogenicity in ■
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys
ADVERSE REACTIONS: The most common adverse events include dizziness or light-headedness,
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of pa-
tients, transient hypotension in about 5%, palpitation in about 2% and syncope in about 0 5%
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antian-
gmal medication Additionally, the following have been reported muscle cramps, nervousness,
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shaki- '
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus, urticaria, fe- ,
ver, sweating, chills, and sexual difficulties. Very rarely, introduction of PROCARDIA therapy was
associated with an increase in anginal pain, possibly due to associated hypotension
In addition , more serious adverse events were observed , not readily distinguishable from the nat-
ural history of the disease in these patients. It remains possible, however, that some or many of
these events were drug related Myocardial infarction occurred in about 4% of patients and conges-
tive heart failure or pulmonary edema in about 2%. Ventricular arrhythmias or conduction disturb-
ances each occurred in fewer than 0.5% of patients.
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline phos-
phatase, CPK. LDH, SGOT, and SGPT have been noted, and a single incident of significantly ele-
vated transaminases and alkaline phosphatase was seen in a patient with a history of gall bladder
disease after about eleven months of nifedipine therapy The relationship to PROCARDIA therapy is
uncertain These laboratory abnormalities have rarely been associated with clinical symptoms
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive world
literature
HOW SUPPLIED: Each orange, soft gelatin PROCARDIA CAPSULE contains 10 mg of nifedipine
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069-2600-66). 300 (NDC 0069-
2600-72), and unit dose (10x10) (NDC 0069-2600-41). The capsules should be protected from
light and moisture and stored at controlled room temperature 59° to 77°F (15° to 25°C) in the man-, j
ufacturer's original container
More detailed professional information available on request © 1982 , Pfizer Inc. j
LABORATORIES DIVISION
PFIZER INC
220
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Quotes from an unsolicited "
?fter received by Pfizer from an
ngina patient.
Vhile this patient 's experience
; representative of many
m solicited comments received,
tot all patients will respond to
Tocardia nor will they all
espond to the same degree
"My daily routine consisted of
sitting in my chair trying to stay alive."
"My doctor switched me to
PROCAR Dl A M as soon as it became
available. The change in my condition
is remarkable."
"I shop, cook and can plant
flowers again."
"I have been able to do volunteer
work... and feel needed and useful
once again"
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again.
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0.5%).
1983, Pfizer Inc.
for the varied faces of angina
Procardia is indicated for the management of:
1 ) Confirmed vasospastic angina.
2) Angina where the clinical presentation suggests a possible
vasospastic component.
3) Chronic stable angina without evidence of vasospasm in
patients who remain symptomatic despite adequate doses of
beta blockers and/or nitrates or who cannot tolerate these
agents. In chronic stable angina (effort-associated angina)
PROCARDIA has been effective in controlled trials of up to
eight weeks' duration in reducing angina frequency and
increasing exercise tolerance, but confirmation of sustained
effectiveness and evaluation of long-term safety in these
patients are incomplete.
FTOCARD1A
(NIFEDIPINE)
Capsules 10 mg
Please see PROCARDIA brief summary on adjoining page
VOL. 81— NUMBER 3— MARCH 1984
221
COMMENTARY:
WHATEVER HAPPENED TO BENIGN NEGLECT?
Michael A. Nevins, m.d., woodcliff lake*
Two cases in New Jersey courts may have a profound effect on
how much autonomy physicians will be permitted in making
critical decisions for chronically ill patients. In the process, the
tradition of benign neglect has taken on an unfortunate
connotation; a more appropriate designation would be
therapeutic restraint.
A century ago. Sir William Osier’s
famous characterization of
pneumonia as “the old man’s
friend” was a serene acknowledgement of nature’s way.
In that more innocent time, treatment options were
few; now the modem physician has acquired a
plethora of potent therapeutic agents along with
previously unthinkable moral and legal dilemmas. One
wonders what Osier would have thought of the recent
spectacle depicted in the national press and on tele-
vision of two California physicians tried for murder
after having terminated respirator and feeding sys-
tems for a comatose patient with the consent of re-
sponsible family members. Closer to home, what would
Osier have thought about two mlings by New Jersey
courts in 1983 which have substantially extended con-
cern about the legal implications of medical decision
making away from relatively uncommon cases of brain
death or coma and closer to the routine practice of
primary care physicians. Both cases involved elderly
institutionalized patients who had chronic but not
“terminal” illness and clinical decisions involved judg-
ments concerning the quality of life. A review of some
features of these important cases is instructive.
THE CLAIRE CONROY CASE
In this case (Conroy, 188 N.J. Super. 523 (1983)),
Judge Reginald Stanton of the State Superior Court,
Chancery Division of Essex County, decided on Febru-
ary 2, 1983, that a nasogastric tube could be removed
from an 84-year-old nursing home patient who suf-
fered from a severe organic brain syndrome and who
was totally dependent upon the tube for nutrition. The
patient had severe dementia, required total care, had
a gangrenous foot, lay virtually immobile in a fetal
position, was mute except to moan when stimulated,
and weighed less than 50 pounds. Miss Conroy’s
guardian had petitioned to permit the nursing home
to remove the feeding tube. The court order was not
carried out because opponents won an immediate stay,
but Miss Conroy died of natural causes 13 days later.
At issue is the question: At what point can a patient,
or someone acting in his/her behalf, refuse basic treat-
ment? Judge Stanton, fully aware of the significance
of his action, in a moving analysis noted the following:
“Life is our most basic possession. The will to stay
alive probably is our strongest instinctive drive. As a
general proposition, the protection of life is one of the
law’s strongest imperatives, and preservation of life is
the major goal of medical practice. The interest of the
state in preserving life is so great that courts have
ordered medical procedures to be performed on pa-
tients even though the patients were competent and
had objected to the procedure. In these cases, however,
*Dr. Nevins is Governor, New Jersey Chapter, American Col- ;
lege of Physicians. Correspondence may be addressed to Dr.
Nevins, 595 Chestnut Ridge Road, Woodcliff Lake, NJ 07675.
222
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
the expectation is that the patient will have a reason-
ably full and vibrant life after the treatment has been
performed. There is a point at which a patient, or
someone acting for him if he is incompetent, has a
right to refuse treatment. That point is reached when
intellectual functioning is reduced permanently to a
very primitive level or when pain has become un-
bearable and unrelievable.
"When we deal with questions such as the ones pres-
ented in this case, a certain basic humility and a sense
of one’s own limitations are appropriate. We know that
mankind's understanding of the ultimate meaning of
life, suffering, and death, is (and probably always will
be) flawed and limited. Many of us believe that an
abiding reverence for life is perhaps our most special
and most worthy human characteristic, but most of us
would agree that when a person has been permanently
reduced to a very primitive intellectual level or one is
permanently suffering from unbearable and un-
relievable pain there is no valid human purpose to be
served by employing active treatment designed to
prolong life. Every sick human being is entitled to
loving care, but there comes a time in the loving care
of some patients when the proper decision is to let
nature take its course, to allow the patient to die.
"Even when we decide that it is proper to withhold
active treatment, it would be wrong to act directly to
terminate life or to withdraw nourishment, fluids,
^shelter, or normal supportive care such as washing
and body positioning. When I say that it would be
Wong to withdraw nourishment and fluids, I mean
jthat it would be wrong to refuse to give them to the
patient if she could take them herself or with the man-
ual assistance of others. It also would be wrong to
withhold medications which would reduce pain
without unduly prolonging life. I conclude that these
things would be wrong because I perceive a need in
this area of decision making: 1) to recognize the limi-
tations of our understanding of life, suffering, and
ideath; 2) to continue a fundamental respect for life
even in the most dire human circumstances; and 3)
to keep in place some fairly simple conceptual controls
designed to give some measure of protection against
ill-informed or badly motivated decisions.”
Judge Stanton felt that, in this instance, the feeding
tube constituted an extraordinary means of treatment.
He acknowledged, however, that although distinctions
between extraordinary and ordinary frequently are
made, such terminology is not helpful and the critical
factor should be the present condition and prognosis
of the patient, focusing on whether life has become,
and is likely to remain, impossibly burdensome to that
patient. He noted further, “Once we human beings
start making choices, we start making mistakes. It is
inevitable that we allow some people to die when we
could have and should have prolonged their lives. But
we cannot let this fear of error force us into abdicating
our basic human responsibility to make choices. The
fear of error should be used constructively as an incen-
tive to make our choices carefully and soundly.” He also
observed that it would be inappropriate to extrapolate
from this case to the treatment of elderly senile pa-
tients or retarded persons of all ages in general, but
that careful distinctions had to be made.
Although Claire Conroy already had died, on July 8,
1983, the Appellate Division of the State Superior
Court, noting the precedent-setting implications of the
Conroy case, reversed the lower court order. They dis-
tinguished Claire Conroy from Karen Quinlan in that
the former neither was in a coma nor in a persistent
vegetative state finding that Miss Conroy still had
many signs of life and that removal of the feeding tube
would inflict new suffering and pain. They felt that
rather than easing her passage from life, removing the
tube would have represented active euthanasia rather
than merely letting die.
It is possible that the Conroy case will be appealed
to the State Supreme Court. The New Jersey Hospital
Association has argued that the Appellate Court ruling
undermines safeguards of local hospital review already
established under the post-Karen Quinlan guidelines
and, thereby, favors increased judicial involvement in
such cases.1
The following should be noted in relation to the
Quinlan case:
1. The ruling permitted the removal of life-support
devices, but did not distinguish between respirators
and artificial feeding systems. It should be recalled that
it was expected that Karen would die as a result of
turning off the respirator. When she did not, her family
chose not to follow through with the next logical step
of terminating artificial feeding, but this was their
choice rather than a legal sanction.
2. The language employed created much confusion.
The Quinlan guidelines were intended for the use of
a patient in a coma although there was and continues
to be some question about whether Karen was in a
coma, a stupor, or a chronic vegetative state. In any
case, the guidelines did not apply to cases of brain
death.
3. The guidelines suggested the formation of prog-
nosis committees or the like, the intention of which
was to verily the clinical prognosis. Curiously, the com-
position of such committees heavily favored lay people
who would seem to be unqualified to make such
clinical determinations. The ultimate decision-making
responsibility remained with the attending physician.
4. The guidelines were only guidelines and
pertained not only to hospitals, but to “health facili-
ties.”
As a result of these ambiguities and legal jargon,
implementation of the Quinlan guidelines has varied
in each of the state’s 101 acute hospitals. Indeed, the
number of hospitals which currently have functioning
prognosis committees is uncertain. Two recent
surveys, using different methodology, have suggested
that between 50 and 84 percent have a formal mecha-
nism that can be activated which is substantially more
than the results of recent national surveys which have
indicated between 1 and 4 percent of hospitals in the
United States have prognosis or ethics committees.*
The position of the New Jersey Hospital Association
relative to the Conroy case is that it would be re-
gressive to return such responsibility to the courts
since the majority of hospitals in New Jersey already
have a functional mechanism that is utilized in cases
of terminating life support according to the Quinlan
guidelines.
‘Personal communications.
VOL. 81— NUMBER 3— MARCH 1984
223
The Appellate Court apparently rejected this logic on
the basis that Miss Conroy demonstrated sufficient
signs of life that she was not in the same terminal
condition as Karen Quinlan. Recall that Miss Conroy,
despite artificial feeding, had wasted to less than 50
pounds and was considered to be in an irreversible
state responding only to noxious stimuli. When visited
by Judge Stanton, she was found to be functioning at
a “near zero level.” Indeed, she died within two weeks
with the tube still in place. Incredibly, the Appellate
Court's conclusion that Miss Conroy was not facing
imminent death was made even though she had died
five months before their decision was announced.
Furthermore, having made this distinction, the Ap-
pellate Court introduced emotional language to sug-
gest that death by dehydration increases suffering
albeit the tube itself and prolongation of the process
of dying might similarly cause discomfort.
Every sick human being is
entitled to loving care , but
there comes a time when the
proper decision is to let
nature take its course .
The Conroy case is bad news for physicians regard-
less of future court actions. If the Appellate Court rul-
ing stands, the case represents a step back from Quin-
lan and makes it virtually impossible to reasonably
distinguish on the basis of the nuances that the court
was able to perceive between the conditions of patients
such as Karen Quinlan and Claire Conroy. It guaran-
tees that the legal system will become increasingly in-
volved in decision making in these already difficult
cases. On the other hand, if the case is challenged and
the Appellate ruling overruled, although this would
reinforce and clarify the Quinlan decision, emphasis
inevitably will be put on more active involvement of
cumbersome prognosis committees in hospitals and,
perhaps, even in nursing homes, with a resultant dif-
fusion of the traditional decision-making process.
Further impetus for this trend already has emerged as
a result of publicity attendant to the “Baby Doe
case”23 as well as the recent recommendation of the
President’s Commission on Biomedical Ethics.4
THE GRECO CASE
The President’s Commission had acknowledged that
in health care “it is common to make decisions that
one knows risk shortening patients’ lives and that
sometimes turn out to do so.” These often are regarded
as cases of “allowing to die” or “not prolonging the
dying process” as distinguished from killing or
hastening death.
Contrasted to the Conroy case, the Greco case ( Greco
OAL DKT No. BDS 5098-81 (1982)), in effect, involved
extension of the concept of letting die now not by
withholding nutrition, but by being insufficiently vig-
orous in pursuing medical treatment for patients the
court felt were not terminal enough.
Dr. Roger Greco, a nursing home medical director,
had his medical license suspended for one year by the
State Board of Medical Examiners because he was
found not to be zealous enough in hospitalizing or
treating elderly nursing home patients who technically
were not suffering from terminal illnesses when they
developed superimposed acute medical illnesses. In the
opinion of the Board, this was a deviation from
standard care and, as such, represented repeated actsj
of negligence, malpractice, or incompetence.
Of the six cases reviewed in detail. Dr. Greco was
exonerated in all but two cases. One of these cases was
an 88-year-old woman who was confused and out ol
contact with reality, had one kidney and chronic renal
failure, and required total care. The clinical records
indicated that she developed pneumonia which, in
turn, exacerbated her renal failure, diabetes, and heart
failure. The patient was not abandoned, but therapy
was initiated at the nursing home where she died after
five days. At one point in the testimony. Dr. Greco
suggested that it was his feeling that it would have
been better to “let her die in peace” than to hospitalize
her for more aggressive therapy. Several medical wit-
nesses, however, felt that supportive care in such a
circumstance was inappropriate since the acute illness
was potentially reversible without using extraordinari-
ly invasive measures and that the patient was not in
a vegetative state, although she required total care, was
incontinent, and responded to most questions only
with moans.
The Greco case presently is being appealed, but its
implications are ominous. It was conceded that the
physician was conscientious and was using his best
judgment even though some considered that judgment
to be flawed. Although the testimony of several expert
medical witnesses indicated that he deviated from
standard care, it is hard to understand how there can
be any real standards in such cases. If there were, they
should be applied to patients in the context of their
total condition and not to an acute disease per se.
However, Judge Sybil Moses did not acknowledge such
a distinction between patient and disease orientation.
She suggested that to offer less than total care unless
the patient is truly vegetative, in agony or imminently
terminal, is inappropriate and that treatment for com-
fort rather than curing goals, while appropriate in a
hospice, is not applicable in a nursing home.
Commenting on the issues of “death with dignity”
or “hospice philosophy” which place into issue the 1
question of passive euthanasia and the assertion of “a
right to die,” Judge Moses said:
“This judge is absolutely certain that such a right ;
to die must be part of an indication of persons who
through some act on their own make their intention
known. Since the New Jersey legislature has not
enacted a natural death act and since none of the
patients in question has enacted any type of living will,
this philosophy is inappropriate to the facts of this
case. Furthermore, the assertion of a hospice
philosophy as the standard of care does not have a
foundation of fact. Hospice care in the United States !
presently is provided at designated centers specifically J
recognized as providing this particular treatment. The
proofs before this judge do not demonstrate that (the
nursing home in question) operated pursuant to this
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
224
Agree*
Strongly
Agree
Strongly
Disagree
1 . The physician should deliver the best care possible at the
nursing home with major emphasis on comfort goals.
Although the home’s facilities are relatively limited, acute
hospitalization is inappropriate under the circumstances.
70%
52%
3%
2. The physician has a right and duty to act independently in
what he believes to be the patient's best interest as he
understands them, there being no identifiable family with
whom to consult.
75%
48%
3%
3. She should be treated the same as any younger patient and
admitted to an acute hospital for aggressive diagnosis and
treatment.
13%
8%
26%
4. Decision making would be enhanced by consultation with
a local committee or court.
10%
6%
32%
‘Includes “agree” and "strongly agree."
Figure — Questionnaire mailed by the New Jersey Chapter, American College of Physicians.
philosophy or had the prior consent of these patients
to withhold the type of treatment suggested by the
state’s experts."
DISCUSSION
Where do the Conroy and Greco cases leave us? It
is disconcerting that even with family concurrence or
with court approval there are no legal guarantees and
so the prudent physician is best advised to proceed
Iwith extreme caution. The courts have ruled that it is
a competent patient's right to refuse treatment and it
|is our responsibility to respect and strive to preserve
those rights. Yet, the proper direction to proceed often
is unclear.
In such cases, much confusion would be averted if
physicians adhered to precise usage of terms, such as
j ‘unconscious,” “stupor,” “coma,” “responsive,” “ter-
minal,” and “brain dead." Fine distinctions that seem
irrelevant or unnecessary at the bedside may prove to
be crucial in effecting a verdict in court.
Regarding terminating artificial feeding, as a result
of the Conroy case, unless a patient is brain dead,
comatose, or death is irreversibly imminent, discon-
tinuing nutrition is not permissible. However, even
when these criteria are met, whether the decision can
be made by physician, committee, or court in New
Jersey, will depend on future appeal of the Conroy case.
Many physicians have found that it is easier, in a legal
sense, not to initiate tube or intravenous feeding
although morally the distinction between not begin-
ning and removing is unclear.4 The propriety of not
starting artificial feeding is still to be tested in the
courts.
For patients who are not considered to be moribund,
but who exist in an extremely limited vegetative state,
it is unlikely that society ever will arrive at a normative
Standard of care.
In July 1983, in order to assess New Jersey phy-
sicians’ attitudes, a questionnaire was mailed to mem-
bers of the state’s chapter of the American College of
Physicians inquiring how they would react to a fic-
titious case that simulated some cases encountered by
Dr. Greco. Results were compiled from the first 202
replies which constituted more than 10 percent of the
organization’s members. There was little variation be-
tween the responses of office-based practitioners,
academicians, or house staff.
The following was the model case: An 85-year-old
woman with no close family resides permanently in a
nursing home. She suffers from Alzheimer’s disease as
well as several chronic disabilities that make her de-
pendent on others for total care. She develops a super-
imposed acute infection and no longer is eating nor
is as responsive as before. The questionnaire then in-
vited responses to four statements (Figure).
Despite the pitfalls of interpreting such an opinion
survey, it is evident that New Jersey internists consider
age and general condition to be important determi-
nants of the intensity of care. Recognizing that individ-
ualization is requisite to good care and believing that
increased involvement of courts and committees into
bedside decision making is regressive, the Council of
the New Jersey American College of Physicians as well
as the New Jersey Society of Internal Medicine adopted
the following statement:
The extent of treatment to be rendered to an
acutely ill geriatric patient remains a subject of
considerable debate within the medical commu-
nity. To date, there are no generally accepted
standards by which a physician may be guided.
Since no such standards currently exist, it is the
position of the New Jersey Chapter of the Ameri-
can College of Physicians that no physician should
be disciplined for providing supportive care, rather
than aggressive care, when treating acutely ill
geriatric patients or, in the alternative, aggressive
care rather than supportive care. Any government
imposed standard on this issue would, at this
time, result in severe hardship upon geriatric pa-
tients and their families. The NJ-ACP strongly op-
poses the imposition of such a government
standard by any regulatoiy body absent a full and
complete review of this most important question.
Most physicians agree that in many cases when
acute illness supervenes it may be more com-
passionate and sensible to do what can be done in the
context of home or nursing home even though the
technical therapeutic capabilities there are less than
VOL. 81— NUMBER 3— MARCH 1984
225
those available in the acute hospital. Such a decision
to pursue limited therapeutic goals rightfully should
be made jointly by physician and family since the
rhythms of court and committee are incompatible with
bedside decision making.6
Much has been written about how and by whom
ethical dilemmas in caring for the ill should be under-
taken.4713 Mechanisms involving predetermined con-
tracts or decisions by consensus generally are imprac-
tical and present problems of logistics, professional
expertise, and objectivity. In the end, the best safe-
guard to maintaining patients’ rights is and always
has been a compassionate and legally unencumbered
physician who has reasonable discretion to act in the
patients’ best interests as he understands them and
who sees his responsibility as not only to take care of
his patients but to care about them.
It is a fact of medical practice that physicians reg-
ularly are involved with decisions that have life and
death implications and unless they are willing to as-
sume the responsibility to act in their patient’s behalf
when that patient cannot participate in the process,
they are not really doing their jobs. As Dr. Arnold
Reiman has remarked, “God protect us from phy-
sicians who make only technical decisions.” In caring
for the elderly senile and the retarded, one must be
particularly careful about premature withdrawal or de-
nial of treatment. Many who suffer from markedly im-
paired intellects may be capable of loving and re-
sponding to love. Whereas it is reprehensible to deny
treatment on the basis of the patient’s age or illness,
to suggest that there is or ever was or ever can be a
single standard of care irrespective of age is misguided.
For example, it is ludicrous to contemplate performing
an invasive procedure such as coronary artery bypass
surgery in a wasted, demented, barely functional pa-
tient. Subjective distinctions always have been implicit
in the weighing of risks and benefits that constitute
clinical medical practice. Nontreatment or limited
treatment is not a corruption, but perhaps the highest
form of what commonly is referred to as the “art of
medicine.” However, in recent years the venerable tra-
dition of “benign neglect” has taken on an unfortunate
connotation. It should not denote either negligence or
abandonment and perhaps a more appropriate desig-
nation would be “therapeutic restraint.”
It is unfortunate that sanctioning such a policy of
therapeutic restraint should be considered as akin to
“a moral domino effect” or a "slippery slope”4 that in-
evitably would lead to abuse. Rather, the converse is
more to be feared, of relentlessly doing all for fear of
being criticized for being nihilistic or negligent. Yet,
the Appeals Court in the Conroy case raised this spec-
tor stating: “To allow a physician or a family member
to disconnect life-sustaining treatment to a person
solely because that person’s lack of intellectual ca-
pacity precludes her from enjoying a meaningful quali-
ty of life would establish a dangerous precedent that
logically could be extended far beyond the facts of a
case before us.”
Fundamental to caring for chronically ill nursing
home patients is that decision making be oriented to
maintenance of function and comfort.13 Limited goals
and therapeutic restraint clearly are not the exclusive
prerogatives of hospices and are applicable in some
cases even when the patient technically is not ter-
minally ill.
Beset by existential and legal doubts, the physician
rarely has the luxury of time to agonize, Hamlet-like,
about the proper course of action. I have always be-
lieved that the best advice for the perplexed clinician
is that of the first century sage Hillel, who when asked
to teach the Torah “while standing on one foot,” re-
plied, “What is hateful to you, do not unto your neigh-
bor; this is the entire Torah, all the rest is commen-
tary.” Would Hillel have been found guilty of malprac-
tice?
REFERENCES
1. Brennan MK The right to die is still unclear. New York
Times, August 28, 1983.
2. Wallace C: Outcry over "Baby Doe" may revive little-used
hospital ethics committee. Modern Healthcare 13:79-80,
1983.
3. Strain JE: The American Academy of Pediatries com-
ments on the “Baby Doe II” regulations. N Engl J Med
309:443-444, 1983.
4. President's Commission For The Study of Ethical Prob-
lems In Medicine and Biomedical and Behavioral Research:
Deciding to forego life-sustaining treatment. Washington,
D.C., U.S. Government Printing Office. 1982.
5. Williams ME, Hadler NM: The illness as the focus of
geriatric medicine. N Engl J Med 308:1357-1359, 1983.
6. Marco CH: For whom the death bell tolls: Who shall live,
who shall die, who shall toll the bell? Legal Aspects Medical
Practice 11:3-8, 1983.
7. Micetich KC, Steinecker PH, Thomasma DC: Are in-
travenous fluids morally required for a dying patient? Arch
Intern Med 143:975-978, 1983.
8. Suber DG, Tabor WJ: Withholding of life-sustaining
treatment from the terminally ill, incompetent patient: Who
decides? JAMA 248:2250-2251, 2431-2432, 1982.
9. Childress JF: Who should decide? in, Paternalism in\
Health Care. Oxford University Press, New York, NY, 1 983. ii
10. Meier DE, Cassel CR Euthanasia in old age: A case!
study and ethical analysis. J Am Geriatr Soc 31:294-298J
1983.
11. Pearlman RA Speer JB: Quality-of-life considerations
in geriatric care. J Am Geriatr Soc 31:1 13-120, 1983.
12. Kass LR Ethical dilemmas in the care of the ill. JAMA
244:1811-1816, 1980.
13. Besdine RW: Decisions to withhold treatment from
nursing home residents. J Am Geriatr Soc, October 1983.
226
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
i
228
COMMENTARY:
THE CONROY CASE
Harvey Rothberg, m.d., princeton*
Further judicial review should clarify the issues in this recent
New Jersey case , and provide appropriate guidelines for the
management of similar cases. Issues include quality of life,
ordinary versus extraordinary care , and whose is the decision-
making responsibility.
New Jersey physicians should be
familiar with the Conroy case
and aware of its implications.1 4
Claire C. Conroy was an 84-year-old spinster who
had a severe organic brain syndrome, as a result of
which she was declared incompetent and she entered
Parklane Nursing Home in 1979. She became bedrid-
den and unable to feed herself; she became unable to
converse, although it was said that she could respond
to commands. She developed necrotic ulcers on her left
foot which were attributed to diabetes. In July 1982,
her physician at Parklane ordered the placement of a
nasogastric feeding tube in Miss Conroy; it was felt
that she was unable to swallow sufficient food or water
to live without such a device. Subsequently, Miss Con-
roy’s condition deteriorated further. She lay in bed in
a fetal position and developed decubitus ulcers on her
left leg and left hip. Despite the feeding tube, she be-
came wasted and her weight was less than 50 pounds.
She became unable to communicate except to moan
in response to noxious stimuli, and it was uncertain
I whether she could experience pain as such.
Her only surviving relative, her nephew and guard-
ian, sought to have the tube removed, but the attend-
| ing physician would not consent to this. In January
1983, the nephew filed a complaint which was brought
before Judge Reginald Stanton of the Essex County
Chancery Division of the Superior Court of New Jersey.
Judge Stanton appointed a lawyer to be guardian ad
litem for Miss Conroy. He also observed the patient in
the nursing home and heard testimony from two phy-
sicians, from the nurse-administrator of the nursing
home, from the nephew, and from Father Joseph
Kikura, a member of the medical ethics committee at
four hospitals and an associate professor of Christian
ethics.
Judge Stanton in his opinion dated February 2,
1983, noted that Miss Conroy’s life had become per-
manently burdensome for her and that prolonging her
life would not help her. He affirmed the right of her
nephew and guardian to direct the removal of the
nasogastric tube. However, Judge Stanton’s decision
promptly was appealed by the court-appointed lawyer,
and the tube was not removed. Nevertheless the pa-
tient expired of natural causes 13 days later.
Even though the death of the patient rendered the
case moot, the Appellate Division chose to continue its
review of the matter because of the importance of the
issues presented. The Appellate Court reversed Judge
Stanton’s decision, holding (in its concluding state-
ment) that a patient such as the deceased should not
be painfully put to death by dehydration and starva-
tion.
In the Appellate Court hearings, Ms. Mary K. Bren-
*Dr. Rothberg is a member of the Princeton Medical Group.
Correspondence may be addressed to Dr. Rothberg, Medical
Arts Building, Suite B, Witherspoon and Franklin Streets,
Princeton, NJ 08540.
VOL. 81— NUMBER 3— MARCH 1984
229
nan argued the case for amicus curiae New Jersey
Hospital Association; they sought to have Judge Stan-
ton’s decision affirmed. The Medical Society was not
involved officially in the proceedings. Now, the New
Jersey Hospital Association has moved the case for
further appeal to the New Jersey Supreme Court. It is
expected that the Supreme Court will consider
thoroughly all the facts as well as the complex issues
involved in order to render a considered judgment in
the matter.
It is essential that the decision of the Appellate
Division be reversed, so that patients, families, and
physicians may have restored to them the options
which naturally and traditionally have belonged to
them.
There are at least four major areas in which the
reasoning of the Appellate Court can be questioned.
First, a major error was the dubious presumption that
the removal of the nasogastric feeding tube would in-
evitably have led to pain and suffering for the patient.
From the clinical point of view, it seems far more likely
that this stuporous patient would instead have grad-
ually lapsed into a coma and expired quietly without
pain or suffering.
Secondly, there is the question of ordinary and ex-
traordinary care. The opinion of the Appellate Court
does address this question at some length, but it de-
clines to resolve the issue. However, what is clear is
that the terms ordinary and extraordinary are relative.
What is “ordinary” treatment for a young, vigorous,
and potentially rehabilitatable individual may be “ex-
traordinary” for another individual whose mental and
physical status have deteriorated irreversibly, whose
quality of life is poor, who is not rehabilitatable, and
who is near the end of his or her life. It is arguable
that the use of a nasogastric feeding tube for a patient
such as Miss Conroy might have been construed by
the patient or her guardian or her physician as ex-
traordinaiy and inappropriate under the circum-
stances.
Contrary to the reasoning of the Appellate Court, I
believe that the removal of a nasogastric feeding tube
in a case like this is not a positive act which inten-
tionally causes death, but rather the removal of an
inappropriate modality of treatment thereby per-
mitting the patient to expire naturally. Thus, removal
of the tube in this case would not be an act of
euthanasia, and would not create a potentially danger-
ous precedent.
The third question deals with the decision-making
responsibility. A medical decision is normally made by
a sentient and informed patient in conjunction with
his or her physician. When the patient is unable to
express himself or to participate in the decision, then
his family must act on his behalf in conjunction with
the physician. (In emergency situations, the physician
may have to act on behalf of the patient without full
consultation.) Only in the exceptional cases where a
conflict or disagreement exists between the normally
deciding parties should it be necessary to have judicial
intervention. A serious defect of the Appellate Court
decision in the Conroy case, if it stands, would be the
removal from families and physicians of some of the
freedom and the options which now are available to
them in their search for the most appropriate and
compassionate means of care of patients for whom
they are concerned.
Parenthetically, it should be noted that the phy-
sician does have a great responsibility in such situ-
ations, yet he must remember that the responsibility
is not his alone. He is not God. He must be careful not
to project his own feelings or his own culture into the
lives of people with different persuasions. The phy-
sician’s role often enough is to decide and to act; but
frequently it primarily is to counsel, to guide, and to
provide information so as to aid a patient or his family
to make the decisions which are appropriate for I
them.5,6
A fourth area of confusion in the Conroy case dis- ,
cussions concerns the question of what constitutes a
terminally ill patient. The Appellate Court decision
states that Miss Conroy was not terminally ill and
suffered from no specific life-threatening illnesses.
This conclusion is highly questionable. It is true that
Miss Conroy did not have cancer or refractory heart,
lung, or kidney failure; but she did have extreme i
malnutrition, inanition, wasting, decubitus ulcera-
tions, and a deteriorated mental and physical state.
The expression “terminal” as applied to advanced ill-
ness means only that the patient is at or near the end
of his course and of his life. Such a definition could
certainly be appropriately applied to Miss Conroy, who
in fact expired just 13 days after Judge Stanton’s de-
cision. (But 1 do not wish to consider this area of
confusion as a governing consideration in the case,
because it may well be held that the question of re-
moval of the feeding tube is not necessarily related to
the question of whether the patient is or is not in a
terminal state.)
Until now we have had in medicine an ethical but
flexible system in which a patient’s relatives and phy-
sician have been able to make decisions on behalf of
a patient and in his best interests as they construe it.
The Appellate Court’s decision in Conroy would create
a restrictive system in which medical options are lim-
ited. In such a system, technology could easily have a
higher value than the humanitarian concerns which
traditionally have operated in the practice of medicine.
That such a flexible or permissive system is accepted
in our society is implicit in the March 1983 report of
the President’s Commission for the Study of Ethical
Problems in Medicine, entitled. Deciding to Forego
Life-Sustaining Treatment7 This superbly conceived
and documented publication represents a balanced
consensus of informed opinion on the issues con-
sidered, and it should be required reading for anyone
wishing to be well informed on the subject. The Com-
mission notes that “the primary goal of health care in
general is to maximize each patient’s well-being.” In
discussing the concept of allowing patients to die, the
Commission states its belief that “most omissions that
lead to death in medical practice are acceptable.” The
Commission concluded that ordinarily a patient’s sur-
rogate “should have the legal authority to make de-
cisions on behalf of an incapacitated patient,” and it
noted further that such “decisions made by surrogates
and physicians now are rarely subjected to court re-
view.”
Experienced and perceptive physicians engaged in
the active practice of medicine are well aware that
230
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
clinical decisions comparable to that exemplified in
the Conroy case are made every week — if not every
day — in American hospitals. Affirmation of the
dubious principles enounced by the Appellate Court
would undoubtedly change medical management in
some cases; but it also would invite flouting the law
in others. Many concerned and loving families and
compassionate physicians would continue to be
guided primarily by their concepts of what is right and
proper for the patient for whom they are caring.
CONCLUSION
For all the above reasons, I believe that the wisdom
and humane concern manifest in the Quinlan decision
and in Judge Stanton’s opinion should be reaffirmed;
and the Appellate Court ruling in the matter of Conroy
should be recognized as a flawed and invalid document
which ought not to be permitted to stand as a restraint
on the provision of humane and appropriate care for
the citizens of New Jersey.
REFERENCES
1. Claire C. Conroy, Superior Court of New Jersey,
Chanceiy Division, Essex County Docket No. P-19083E.
Rendered by Judge Reginald Stanton.
2. Claire C. Conroy, Superior Court of New Jersey, Ap-
pellate Division, A-2483-82 Tl. Rendered by Judges Herman
D. Michels, Sylvia B. Pressler, and Theodore W. Trautwein.
3. Sullivan R Court in Jersey forbids removing feeding
tube from terminally ill. New York Times, July 9, 1983.
4. Brennan MR New Jersey opinion: The right to die is still
unclear. New York Times, Aug. 28, 1983.
5. Rothberg H: Patients and physicians, life, and death.
Pastoral Psychology 23:15-26, 1972.
6. Swazey JB: Treatment and nontreatment decisions: In
whose best interests? in, Dilemmas of Dying: Policies and
Procedures for Decisions Not to Treat G.R Hall, 1982, pp
95-101.
7. President’s Commission for the Study of Ethical Prob-
lems in Medicine: Deciding to forego life-sustaining treat-
ment. U.S. Government Printing Office, March 1983.
VOL. 81— NUMBER 3— MARCH 1984
231
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232
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
i
Housing Application
218th ANNUAL MEETING
THE MEDICAL SOCIETY OF NEW JERSEY
MAY 3-6, 1984
Single
Twin
Suites
Resorts International
$80.00
$80.00
$171/$250
(headquarters hotel)
Harrah’s Marina Hotel Casino
$75.00
$75.00
World International Hotel/Motel
$58.00
$58.00
Lafayette Motor Inn
$58.00
$58.00
Rates subject to 12% state and
local taxes; tax subject to
change.
All hotel reservations for the 218th Annual Meeting of MSNJ will be handled by the Atlantic City Convention
Bureau. Please send your housing application with your 1st, 2nd, and 3rd choices directly to the Bureau, 16 Central
Pier, Atlantic City, NJ 08401. All Delegates and Members are urged to make their hotel reservations early. Blocks
of rooms will be available at Resorts International (headquarters hotel), Lafayette Motor Inn, World International
Hotel/Motel, and Harrah’s Marina Hotel Casino. The cut-off date for reservations will be April 6, 1984. Reservations
cannot be guaranteed after this date. No Saturday arrivals please. All registrants will be charged for three nights:
Thursday, Friday, and Saturday, May 3, 4, and 5, 1984.
MAIL THIS APPLICATION DIRECTLY TO THE ATLANTIC CITY CONVENTION BUREAU
16 Central Pier
Atlantic City, NJ 08401
Please list 1st, 2nd, and 3rd choices; confirmation will come directly from hotel.
1st Choice 2nd Choice
3rd Choice.
Accommodations desired: □ Single □ Twin □ Suite Parlor & 1 Bedroom
□ Suite Parlor & 2 Bedrooms
Name
Address.
City
State
Zip.
Phone.
Will arrive.
-Time-
date
□ Check if Official Delegate
.Will depart
County .
-Time
date
VOL. 81— NUMBER 3— MARCH 1984
233
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234
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
DOCTORS’
NOTEBOOK
Trustees ' Minutes;
President's Column; UMDNJ
Notes; MSNJ Auxiliary;
AMNJ Report; Physicians
Seeking Location in New
Jersey
Trustees* Minutes
January 15, 1984
A regular meeting of the Board of
Trustees was held on Sunday, Janu-
ary 15, 1984, at the Executive Of-
fices in Lawrenceville. Detailed
minutes are on file with the sec-
retaiy of your county society. A sum-
mary of significant actions follows:
Report of the President . . .
Physician Reimbursement Under
DRG . . . Noted that if a plan to re-
imburse physician services under
DRG is proposed, MSNJ would take
aggressive steps to oppose the pro-
ject. Noted that this discussion was
in reference to the situation at
Shore Memorial Hospital and that
Mr. Maressa will pursue clarification
of the issue.
Report of Executive Director . . .
(1) MSNJ Paid Membership . . .
Noted that as of December 3 1 , 1983,
there were 7,527 dues-paid mem-
bers.
(2) AMA Delegation Allocation . . .
Noted that MSNJ is awaiting official
notification as to the number of New
Jersey physicians recorded as AMA
members that will affect the AMA
delegate allocation for 1984.
(3) DRG Waivers . . . Noted that
while the implementation ofTEFRA
parts A and B billing have been
suspended, it is anticipated that
TEFRA requirements will be en-
forced in New Jersey by January
1985, and all hospital-based phy-
sicians should be prepared for that
eventuality.
( 4 ) Corporate Practice of Medicine
. . . Noted that for-profit corpor-
ations that are not professional ser-
vice corporations may not engage in
the practice of medicine or employ
individuals to practice medicine
(with the exception of hospitals) ac-
cording to a recently rendered
opinion by Deputy Attorney General
Goltz.
(5) MSNJ Financial Statements
. . . Approved the financial state-
ments for the period ending Decem-
ber 31, 1983.
(6) Annual Meeting . . . Em-
powered the Committee on Annual
Meeting to move the Annual Meet-
ing from Resorts International
Casino-Hotel if Resorts Inter-
national does not abide by the
signed contract. Note: Resorts Inter-
national Casino-Hotel informed
MSNJ that because they are in the
process of renovation, they cannot
provide all the room accommo-
dations and hospitality suites as
committed: Resorts International
was informed that their amended
contract was unacceptable and
MSNJ is awaiting a response.
NJ Hospital Association . . .
Health Care Costs . . . Referred to
the Council on Public Relations the
issue of dealing with the high costs
of health care, prompted by an
article in the New England Journal
of Medicine entitled, “Rationing
Hospital Care: Lessons from
Britain.”
Council on Mental Health . . .
(1) Prescriptions for Controlled
Substances — Manner of Issuance of
Prescriptions . . . Approved the fol-
lowing recommendation:
That the Board of Trustees advises the
Department of Health that the 30-day
limitation, after the date issued, for fill-
ing prescriptions for controlled
substances be expanded to include all
drugs.
(2) Quality of Patient Care at State
Psychiatric Institutions and Com-
munity Mental Health Centers in
New Jersey . . . Approved the follow-
ing recommendation:
That the Board of Trustees appoints
an ad hoe committee, with equal rep-
resentation from MSNJ and the New Jer-
sey Psychiatric Association, to in-
vestigate patient care and management
in state psychiatric institutions and
community mental health centers in New
Jersey.
Council on Public Health . . .
Report of the Special Committee on
Cancer Control . . .
(1) Oncology Society of New Jer-
sey. . . Referred back to the Special
Committee on Cancer Control for
further information the following
recommendation:
That physicians in the state who are
involved in tumor work be identified and
urged to join the Oncology Society of New
Jersey.
(2) Establishment of a Cancer
Control Coordinating Council . . .
Approved the following recommen-
dation:
That the Medical Society of New Jersey
approves the establishment of a Cancer
Control Coordinating Council.
Old Business . . .
(1) Urgi-Centers . . . Noted that
when urgi-centers are opened in
New Jersey, law requires licensure
and a certificate of need, except
when owned and operated by phy-
sicians in their private practice.
(2) New Medical Staff Standards
. . . Noted that the JCAH’s Board of
Commissioners approved rewritten
“medical staff standards:”
The new “Medical Staff’ chapter
allows hospitals either to retain or
modify the existing composition of
their medical staff. Under the new
standards, there will be a single or-
ganized medical staff that includes
licensed physicians. In addition, at
the option of the hospital, the staff
may include other licensed individ-
uals permitted by law and the hospi-
tal to provide patient care services
independently (without supervision
or direction). The JCAH has not
changed its posture on the ap-
propriateness of having dentists as
members of hospital staffs. The in-
tent of the new standards is to in-
dicate that the hospital may broad-
en its medical staff if such action
seems appropriate. Peer recommen-
VOL. 81— NUMBER 3 — MARCH 1984
235
dations should be considered when
granting medical staff membership.
The new chapter states that a ma-
jority of the medical staff executive
committee must be physician mem-
bers of the medical staff. The ex-
ecutive committee is responsible for
making recommendations to the
governing body concerning at least:
the structure of the medical staff,
mechanisms for reviewing creden-
tials and delineating clinical privi-
leges, membership on the medical
staff, clinical privileges for eligible
individuals, medical staff quality as-
surance activities, mechanisms for
terminating medical staff member-
ship, and fair hearing procedures.
Clinical privileges are required for
all members of the medical staff and
also for those who are not members
of the medical staff, but who provide
patient care services independently.
Peer recommendations should be
considered when clinical privileges
are being granted. AJ1 practitioners
with privileges must comply with
the bylaws, rules, regulations, and
policies of the medical staff and have
the quality of their care reviewed
through the hospital's quality as-
surance program.
The granting of admitting privi-
leges must be in accordance with
state law and criteria developed by
the medical staff from standards of
medical care. The new “Medical
Staff’ chapter limits admitting privi-
leges to members of the medical
staff. The general medical condition
of a patient is the responsibility of
a qualified physician member of the
medical staff. When nonphysician
medical staff members are granted
the privilege to admit, their patients
must undergo a prompt medical
evaluation by a qualified physician.
This requirement does not apply to
qualified oral surgeons who have
been granted the clinical privilege to
perform a history and physical
examination for patients without
medical problems.
In the new “Medical Staff’
chapter, responsibility for monitor-
ing and evaluating the quality and
appropriateness of patient care and
the clinical performance of all indi-
viduals with clinical privileges is re-
tained by the medical staff. The
standards require that important
problems in patient care be iden-
tified and resolved and that op-
portunities to improve care be ad-
dressed. The Accreditation Manual
for Hospitals specifically addresses
medical staff monitoring activities
in medical department s/services,
surgical case review, pharmacy and
therapeutics review, medical records
review, blood usage review, and anti-
biotic review.
New Business . . .
(1) Proposed New Rule on
Advertising and Solicitation Prac-
tices—N.J.A.C. 13:35-6.10 . . .
Sent a letter to the State Board of
Medical Examiners noting MSNJ’s
comments on the following para-
graphs:
Paragraph (h) would appear to present
an unwieldy format in requiring that all
the principals, partners, or officers must
be identified, especially when there are
three or more licensees in a given prac-
tice. Under paragraph (i), the issue of
joint and severe liability, however, should
not be applicable unless all principals,
partners, or officers have contributed to
the controlling vote.
(2) AMA National Conference on
the Impaired Physician . . . Noted
that the 6th AMA National Con-
ference on the Impaired Physician is
to be held on September 5-8, 1984,
at the Meadowlands Hilton in
Secaucus.
(3) JEMPAC Meeting . . . Noted
that William E. Ryan, M.D., Chair-
man of JEMPAC, invited Board
members to attend the special JEM-
PAC Board of Directors meeting on
January 26, 1984, when Thomas R.
Berglund, M.D., Secretaiy of AMPAC,
will be the guest speaker.
President’s Column
Alexander D. Kovacs, M.D.
There are two physicians for each
one licensed to practice medicine.
There is you and the public per-
ception of you. The “other doctor” to
a large extent is a media creation.
The public tends to believe he/she is
the real you.
Depending upon whether they
watch “General Hospital” or "St.
Elsewhere," your electronic image is
that of a young (usually), good-look-
ing (always), lecherous (most of the
time), well-heeled (absolutely) hero
(villain). On one hand, your real-life
patients get an exaggerated idea of
your virtues and talents; on the
other hand, they get an exaggerated an<
idea of your venality and in- ^
competence, to say nothing of your a I
sexual prowess. 6°
Your media image performs in- no
credible feats of diagnosis and dra- a1
matic “edge-of-the-cliff” sur- »'
gery — your cures are nothing short »
of miraculous. Your patients walk n(
into your office looking for a com- af
bination of Paul Newman and Albert i a
Schweitzer and find you. There is a
certain letdown.
P
Alexander D. Kovacs, M.D.
At least as bad is the other side of
the media coin— the money-hungiy
incompetent. The patients watching
these programs come to your office
expecting a combination of Bela
Lugosi and Billy the Kid and there
you are, Mr. Nice Guy. But they are
not buying your act. They are so
suspicious that they are off to see a
lawyer if you say or do the least little
thing that seems odd.
Our profession is served equally
poorly by the straight news depart-
ments of television, radio, news-
papers, and magazines. Premature
release of information concerning a
new drug or a new procedure can
cause a stampede of people demand-
ing a prescription or the latest
surgical miracle. If a reporter smells
out an article in a professional
journal noting potentially adverse
reactions to a drug in use, he
trumpets the news to the skies and
thousands of people throw away
their pills often to the detriment of
their health.
Whether positive or negative, the
end results of sensationalized media
are inappropriate expectations,
fears of treatment, increased costs.
236
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
and unjustified malpractice actions.
How often have you seen news of
a large award blazoned across the
front page of the paper? Did you ever
notice where they hide the news of
a reversal or reduction of the same
award? On one page, a newspaper
will headline a life-prolonging tech-
nological breakthrough and on the
next bemoan the high cost of medi-
cal care.
Complaining about this seems
churlish. We are in a high profile
profession. My concern is that
media distortion creates real health
hazards for our patients. Our job,
therefore, is to educate them as to
the difference between reality and
fantasy, between reasonable hope
and a fairy tale ending, between
scare stories and sober truths.
There is responsible journalism
and there is responsible medicine.
We cannot do much about the first
but we can demonstrate our ability
to provide the latter. In the long run,
i that is the only real refutation we
■can make.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
Norman H. Edelman, M.D., pro-
fessor of medicine and physiology
and associate dean for research at
UMDNJ, Piscataway, has been ap-
pointed acting director of the state’s
proposed major new center for ad-
vanced biotechnology, a joint project
between UMDNJ and Rutgers, the
State University.
Dr. Edelman’s appointment was
announced in January by both uni-
versities after Governor Kean’s Com-
mission on Science and Technology
strongly endorsed the development
of a biotechnology center in
Piscataway as part of an extensive
package of recommendations aimed
at readying New Jersey for the high-
technology era The proposed center
will draw on the existing resources
of both universities, while fostering
cooperative working relationships
with other research institutions in
the state, including private industry.
The center’s primary focus will be
fundamental research in areas such
as genetic engineering, molecular
biology, microbiology, biochemistry,
and basic pharmacology. The Com-
mission indicated that developing
the center would require an esti-
mated capital expenditure of $40
million. The financing will be ad-
dressed through a joint bonding in-
itiative involving the state, Rutgers
University, and UMDNJ.
Two major grants recently
awarded to the department of pedi-
atrics of UMDNJ-Rutgers Medical
School, Piscataway, will enable its
Division of Child Development to
focus on communication disorders
in infants and young children.
Michael Lewis, Ph.D., professor of
pediatrics, will be director of both
the Center for Communication Dis-
orders, which is beihg established
with funding from the Robert Wood
Johnson Foundation, and the
Language Interaction Intervention
Program, which is funded by a grant
from the U.S. Department of Educa-
tion. The four-year, $600,000 Robert
Wood Johnson Foundation grant is
unique in its focus on children in
the 0 to 3 age group and its utiliza-
tion of an already-existing health
network of primary care physicians
and communication specialists.
The geographic area to be served
encompasses Monmouth, Middle-
sex, Mercer, and Somerset counties
and includes some 59,000 children
under 3 years of age, of which at
least 2,900 have or are at risk for
communication disorders. Three
major groups to be targeted are
physicians, parents (who will learn
from these physicians how to be
more aware of possible developmen-
tal problems), and communication
specialists such as speech
pathologists, audiologists, and
learning disability consultants. The
normal pediatric examination is not
oriented toward detection of the
more subtle communication dis-
orders. The program would refine
current statewide screening
procedures. New Jersey law man-
dates the screening of all newborns
for hearing loss and provides for fol-
lowup examinations and inter-
vention programs for children found
to be at risk for communication dys-
function.
The three-year, $400,000
language intervention grant from
the U.S. Department of Education
will focus on language-delayed chil-
dren within the existing system of
infant stimulation programs in the
greater New Brunswick area. These
programs are part of a statewide sys-
tem established by the New Jersey
legislature to provide intervention
and educational services for handi-
capped preschool children.
While these centers deal with a
great diversity of children who often
have multiple developmental prob-
lems, Dr. Lewis will focus on com-
munication disorders. Children par-
ticipating in the program at Rutgers
Medical School will work with a
speech pathologist while their
parents will be taught how to inter-
act in special ways with their chil-
dren.
MSNJ Auxiliary
Gale Wayman
President
“Gaining the MD— Is the Glamor
Gone?” is the title of an article in the
January issue of FACETS, the AMA
Auxiliary magazine. Becoming a
physician today has become a
tremendous financial burden for
would-be physicians and their fami-
lies. A medical degree translates into
an average debt of $40,000 for each
graduate of a public medical school
and $80,000 for each graduate of a
private school. Tuitions are up
sharply, to as high as $19,500 a year
at schools like Georgetown and
George Washington Universities in
Washington, D.C.
At the same time, the physician
population of the United States has
increased, to the point that some
physicians today are less willing to
support such projects as the Medical
Student Loan Fund and AMA-ERF.
You are not contributing to your
competition; but to better medicine!
AMA-ERF was established in 1951
to help assure quality medical
education and to assist research in
the nation’s medical schools. To
date, AMA-ERF has contributed
more than $37 million in un-
restricted grants directly to the na-
tion’s medical schools. Contribu-
tions to the fund are accumulated
through the year and distributed
annually to designated medical
schools. Your AMA-ERF donations
can be designated to benefit the
medical school of your choice, such
as your alma mater.
The Foundation also has an Un-
restricted Fund which helps support
special health and medical pro-
VOL. 81— NUMBER 3— MARCH 1984
237
grams and research, or donors can
specify research in such fields as
neuromuscular diseases, metabolic
and endocrine diseases, and
arthritis and rheumatism.
When your county auxiliary has
fundraising projects for AMA-ERF
and Medical Student Loan Fund,
will you please give for better medi-
cine in America!
AMNJ Report
Paul J. Hirsch
President
The Academy of Medicine of New
Jersey is pleased to announce that
Joseph R Ruggles of Springfield,
Ohio, has been appointed to the new
position of Associate Director for
Continuing Education. Mr. Ruggles
presently is Director of Continuing
Education at the Community Hospi-
tal of Springfield arid Clark County,
in Springfield. He will be joining the
Academy this spring. Mr. Ruggles
was selected by the Search Commit-
tee from over 100 applicants for the
position.
The Academy of Medicine annual
Internal Medicine Review Course
began on Wednesday, January 11,
1984. It will be held on 19 con-
secutive Wednesdays, at Overlook
Hospital. There was record regis-
tration ten days before the program
started, and additional registrants
were expected.
The First Wednesday program re-
sumed on February 1, 1984. The
speaker was Dr. James Todd. His
topic was "The Medical-Social-Eco-
nomic Considerations in the Prac-
tice of Medicine in the Future." As
is customary, this was a luncheon
meeting, held in the headquarters
building.
On January 18, 1984, the
Academy presented another in its
series of Controversies in Medicine.
This was a symposium on Con-
troversies in Geriatrics. T. Franklin
Williams, M.D., the Director of the
National Institute of Aging of the
NIH, was the keynote speaker.
On January 17, 1984, the Board of
T rustees of the Academy of Medicine
selected the recipients for the 1984
Edward J. Ill Award, and the Citizens
Award. These names will be included
in my report to the MSNJ Board next
month.
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ANESTHESIOLOGY— Jan Charles Hor-
row, M.D., 131 Pond Brook Rd..
Chestnut Hill, MA 02167. Penn-
sylvania 1977. Board certified. Group,
academia, HMO. Available.
CARDIOLOGY — Aubrey Orrin Lewis,
M.D., 200 Carman Ave., Apt. 21-F, East
Meadow, NY 1 1 554. SUNY-Syracuse
1979. Also, general internal medicine.
Board certified (1M). Solo, partnership,
group, academia (cardiology). Available
July 1984.
FAMILY MEDICINE — Jaime F. Lara,
M.D., 6045 Palisade Ave., West New
York, NJ 07093. Seville (Spain) 1979.
Board eligible. Partnership or institu-
tionally based. Available.
GASTROENTEROLOGY— Albert M
Harary, M.D., 2121 N. Bayshore Dr.,
Apt. 1001, Miami, FL33137. Columbia
1978. Also, general internal medicine.
Board certified (IM). Group, partner-
ship, solo. Available July 1984.
Prakash V. Huded, M.D., 80-15 41 Ave.,
** 606, Elmhurst, NY 1 1373. Kamatak
(India) 1970. Board certified. Solo,
group, partnership. Available.
H.L. Kirsehenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Med. College 1977. Board eligible.
Also, internal medicine. Partnership,
group, full-time hospital. Available July
1984.
P. Kothanda Raman, M.D., 9 Lake Ave.,
Apt. 5A East Brunswick, NJ 08816.
Stanley Medical College (India) 1977.
Board eligible (IM). Also internal medi-
cine. Partnership, group, solo. Avail-
able July 1984.
INTERNAL MEDICINE— Nicholas
Bertini, M.D., 663 Hudson Ave., Albany,
NY 12203. SUNY-Buffalo 1980. Board
eligible. Group, partnership, solo. Avail-
able June 1984.
Harold J. Brown, M.D., 260 Eggerts
Rd., Lawrenceville, NJ 08648. UMDNJ
1982. Primary care clinic, HMO, group,
partnership. Available July 1985.
Palamadai S. Duraiswami, M.D., 64-A
Oneida Ave., Centereach, NY 1 1 720.
Stanley Medical College (India) 1976.
Board eligible. Available.
Z.UA Farooqui, M.D., Plaza Pro-
fessional Bldg., Bayshore Rd. and
Greenwood Ave., Box 238, Villas, NJ
08251. Aurangabad Medical College
(India) 1972. Board eligible. Group or
partnership. Available.
Elliott Friedman, M.D., 25 Penny La,
Baltimore, MD 21209. SUNY-Syracuse
1978. Subspecialty, endocrinology.
Board certified (IM); board eligible (M).
Group or partnership (both special-
ties). Available July 1984.
H.L. Kirsehenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Med. College 1977. Board eligible.
Also, gastroenterology. Partnership,
group, full-time hospital. Available July
1984.
P. Kothanda Raman, M.D., 9 Lake Ave.,
Apt. 5A, East Brunswick, NJ 08816.
Stanley Medical College (India) 1977.
Board eligible. Also, gastroenterology.
Partnership, group, solo. Available July
1984.
Andrew L. Saporito, Jr„ M.D., 28
Grandview Ave., West Orange, NJ
07052. Guadalajara (Mexico) 1976.
Group or partnership. Available.
Steven Wolinsky, M.D., 1404 E. 15 St.,
Brooklyn, NY 1 1230. Case Western Re-
serve 1980. Group or partnership.
Available July 1984.
NEPHROLOGY— Arvind Mehta M.D.,
8051 N. Hanover St., Anaheim, CA
92861. Seth G.S. Medical College
(India) 1975. Also, internal medicine.
Board eligible. Solo, group, partner-
ship. Available.
NEUROLOGY — Elizabeth Kamenar,
M.D., 12701 Shaker Blvd., Apt. 410,
Cleveland, OH 44120. Ohio State 1975.
Board eligible. Group, partnership,
academia Available July 1984.
Robert P. Rubens, M.D., 105 Ward St.,
Apt. 204, Seattle, WA 98109. UMDNJ-
New Jersey Medical School 1980.
Board eligible. Available July 1984.
OBSTETRICS/GYNECOLOGY— Alan M
Askinas, M.D., 1309 Carrollton, Apt.
321, Metairie, LA 70005. Illinois 1980.
Board eligible. Group, partnership,
solo, part academia Available July
1984.
Wook Chung, M.D., 2212 Watterworth
Dr., Kalamazoo, MI 49008. Catholic
Medical College (Korea) 1967. Board
certified. Solo, group, partnership.
Available.
Iris E. Dominy, M.D., 108 Pinegate Cir-
cle, Apt. 2, Chapel Hill, NC 27514.
Albany 1978. Board eligible. Partner-
ship or group in metropolitan area
Available July 1984.
OPHTHALMOLOGY— Steven R. Davis,
M.D., 1000 Lakeview Rd„ Clearwater,
FL 33516. University of Alabama 1975.
Board certified. Solo or association.
Available.
Andrew Gewirtz, M.D., 519 Beach 133
St., Belle Harbor, NY 11694. Chicago
1978. Board eligible. Board certified
(PD). Group or partnership. Available
July 1984.
PATHOLOGY— Mark A. Grathwhol, M.D.,
2510 West Tremont Ct„ Richmond, VA
23225. NYU 1980. Group. Available
July 1984.
Yuiy Kogan, M.D., 60 Egmont St.,
238
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Brookline, MA 02146. Moscow 1967.
Hospital or group. Available July 1984.
PEDIATRICS — Jonathon J. Evans, M.D.,
1800 Calvin Ct„ #6, Iowa City, IA
52240. Univ. of Califomia-San Diego
1981. Board eligible. Group or HMO.
Available July 1984.
Michael J. Foreman, M.D., 2527
Hydraulic Rd., #52, Charlottesville, VA
22901. Hahnemann 1981. Board
eligible. Group or partnership. Avail-
able July 1984.
PSYCHIATRY— Eric M. Levin. M.D., 43
West 8th St„ Media, PA 19063. La Fac-
ulty Libre de Medicine (Spain) 1980.
Board eligible. Group, institutionally
based, CMH outpatient. Available July
1984.
PULMONARY DISEASES— James
Kohan. M.D., 19 Highmanor Dr„ Hen-
rietta, NY 14467. Virginia 1979. Also,
general internal medicine. Board
certified (IM). Group, partnership, solo,
institutional. Available July 1984.
Dinesh Talati, M.D., 66-02 Grand Cen-
tral Pkwy., Forest Hills, NY 1 1375. B.J.
Medical College (India) 1974. Board
eligible. Solo, group, partnership. Avail-
able July 1984.
RADIOLOGY/ NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon
St., Apt. 3B, Brookline, MA 02146. Bos-
ton 1976. Board certified. Group or
partnership. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond
Brook Rd., Chestnut Hill, MA 02167.
Med College of Pennsylvania 1980.
Board eligible. Group, HMO, academia.
Available.
RHEUMATOLOGY— Richard Furie, M.D.,
435 E. 70th St., Apt. 8-F, New York, NY
10021. Cornell 1979. Also, general
internal medicine. Board certified (IM).
Group, partnership, solo. Available July
1984.
SURGERY, GENERAL— Ramon J.
Gomez, M.D., 40-71 Gleane St.,
Elmhurst, NY 1 1373. University of the
East (Philippines) 1978. Group or hos-
pital-based emergency medicine prac-
tice. Available.
F. Andrew Morfesis, M.D., 7545 Rogers
Ave„ Upper Darby, PA 19082. Penn
State (Hershey) 1979. Board eligible.
Available July 1984.
SURGERY, ORTHOPEDIC— Jeffrey H.
Charen, M.D., 155 Lexington St„ Apt.
15, Aubumdale, MA 02166. Rochester
1978. Board eligible. Group, partner-
ship, solo (central or northern NJ
preferred). Available.
Richard Lebovicz, M.D., 415 Grand St„
New York, NY 10002. SUNY-Downstate
1979. Group or partnership. Available
July 1984.
UROLOGY — Joseph G. Colonna, M.D.,
1234 Van Voorhis Rd„ Apt. C-6,
Morgantown, WV 26505. Guadalajara
(Mexico) 1977. Board eligible. Group or
partnership. Available October 1984.
For patient’s
comfort/convenience
in choice of
LIPO-NICIN
Nicotinic Acid Therapy
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug.
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
(BWctiMfc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 lW®
VOL. 81— NUMBER 3— MARCH 1984
(
THE ACADEMY OF MEDICINE OF NEW JERSEY
in cooperation with
NEWARK BETH ISRAEL MEDICAL CENTER
presents a symposium on
‘NEONATAL ULTRASOUND”
on
Saturday, April 14, 1984
at
NEWARK BETH ISRAEL MEDICAL CENTER
201 Lyons Ave.
Newark, N.J.
The program will include presentations by nationally
prominent speakers on ultrasound— principles and
safety; early pregnancy; intra and extra uterine; placen-
tal growth and grading: fetal echocardiography; fetal
anatomic abnormalities; neonatal intracranial anatomy
and hemorrhage; pregnancy dating and I.U.C.R.; and
routine use of ultrasound— yes or no. The program is
designed for pediatricians, gynecologists, radiologists,
primary care physicians, and other interested pro-
fessionals.
For further information, please contact:
6emyo^ EXECUTIVE OFFICES
% The Academy of Medicine of New Jersey
.c wM&m § Two Princess Road
0 Lawrenceville, NJ 08648
of New Jersey (609) 896-1717
V LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
WEDNESDAY, APRIL 4, 1984
PERIPHERAL VASCULAR DISEASE
MODERATOR: ABDULMASSIH S. ISKANDRIAN, M.D.
3:00 CASE PRESENTATION Daniel Mason, M.D.
3:30 DIAGNOSIS AND MANGEMENT OF DISSECTING ANEURYSM Harold Kay, M.D.
4:00 ABDOMINAL AORTIC ANEURYSM: DIAGNOSIS AND
INDICATIONS FOR SURGERY
4:30 THE ASYMPTOMATIC CAROTID BRUIT
5:00 PERIPHERAL VASCULAR DISEASE: DIAGNOSIS AND
MANAGEMENT
5:30 PANEL DISCUSSION
LECTURE HALL “A”— 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
**WINE & CHEESE SERVED FOLLOWING CONFERENCE**
Sheldon R. Bender, M.D.
Joseph R. Carver, M.D.
David Naide, M.D.
THE ACADEMY OF MEDICINE OF NEW JERSEY-
ORTHOPAEDIC SECTION
THE NEW JERSEY ORTHOPAEDIC SOCIETY
UMDNJ-N.J. MEDICAL SCHOOL— ORTHOPAEDIC DIVISION
ST. JOSEPH’S HOSPITAL AND MEDICAL CENTER-
ORTHOPAEDIC DEPARTMENT
present the
NINTH ANNUAL
N.J. ORTHOPAEDIC SYMPOSIUM
on
Saturday, April 7, 1984
8:00 A. M. -4:00 P.M.
at
UMDNJ-RUTGERS MEDICAL SCHOOL
Piscataway, NJ
The program will include presentations by nationally
prominent speakers on long term results of total con-
dylar knee arthroplasty; revision total hip surgery; the
girdlestone operation revisited; complications in the
treatment of congenital hip disorders under walking
age; treatment of painful hip in the young adult; early
diagnosis of avascular necrosis of the femoral head and
some approaches to treatment; posterior syndromes of
the ankle in classical ballet dancers; as well as abstract
presentations by New Jersey Orthopaedists.
For further information, please contact:
MS. LINDA BAFSTOLO
^ %. The Academy of Medicine of New Jersey
§ Two Princess Road
O
<D
0 Lawrenceville, NJ 08648
of New Jersey
(609) 896-1717
240
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CME CALENDAR
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsor for further
information.
This list is compiled through the coop-
eration of the Committee on Medical
Education of the Medical Society of New
Jersey, the Academy of Medicine of New
Jersey, the New Jersey Chapter of the
American Academy of Family Phy-
sicians, and the Office of Continuing
Medical Education of the UMDNJ. For
information on accreditation, please
contact the sponsoring organization (s),
indicated by italics — last line of each
item.
ANESTHESIOLOGY
Apr.
16 Pain Therapy
11:30 A.M.- 12:30 P.M. —Columbus
Hospital, Newark
(AMNJ)
CARDIOLOGY
Apr.
1 Cardiac Doppler
28 Quantitative Echocardiography
29 Left Ventricular Function by M -
Mode, 2D, and Doppler
Echocardiography
9 A.M.- 5:30 P.M. —Nassau Inn,
Princeton
(Practical Diagnostic Ultrasound
Seminars and AMNJ)
1 7 Management of Unstable Angina
12 noon — St. Mary’s Hospital,
Orange
(AMNJ)
25 Management of Acute Myocardial
Infarction
1 -2:30 P.M. — VA Medical Ctr., Lyons
(VA Medical Ctr. and AMNJ)
May
2 Recent Advances in
Echocardiology
1 2:30 P.M. —Christ Hospital. Jersey
City
(Christ Hospital and AMNJ)
2 Cardiovascular Evaluation and
Treatment of Patients with
Recurrent Syncope
9-1 1 P.M — Middlesex General
Hospital, New Brunswick
(Middlesex General-University
Hospital and AMNJ)
5 Advanced Echocardiography
6 9A.M 5 P.M. —Center for Health
Affairs, Princeton
(The National Foundation for Non
invasive Diagnostics and AMNJ)
19 Prosthetic Cardiac Valves
20 Summary of M-Mode, 2D, and
Doppler Echo Features for
Acquired and Congenital Cardiac
Lesions
9 A.M. 5:30 P.M. —Nassau Inn,
Princeton
(Practical Diagnostic Ultrasound
Seminars and AMNJ)
MEDICINE
Apr.
2 Laser Treatment— GI
1 :30 P.M. —Columbus Hospital,
Newark
(AMNJ)
4 Medical Grand Rounds
1 1:30 AM— VA Medical Center,
East Orange
(Endocrinology Section. AMNJ)
4 Common Foot Problems
1 8 Acne
1 :30-2:30 P.M. — Rutgers
Community Health Plan, 57 U.S.
Hwy # 1 , New Brunswick
(Rutgers Community Health Plan
and AMNJ)
4 Alcoholism
1 :30 P.M. —Essex County Hospital
Ctr., Cedar Grove
(AMNJ)
4 Antibiotic Nephrotoxicity
1-2:30 P.M.— VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
4 Hypertension in the Elderly
25 Paget’s Disease
1-2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
4 Cutaneous Manifestations of
Systemic Diseases
1 1 Medical Treatment of Gallbladder
Disease
1 8 Osteoporosis and Kidney Stones
25 The Powerful New Role of
Monoclonal Antibodies in Medical
Diagnosis and Treatment
9-1 1 A.M.— Middlesex General-
University Hospital, New Brunswick
(Middlesex General-University
Hospital and AMNJ)
4 Endocrine Conferences
1 1 3:30-5 P.M — Rotates between
18 Newark Beth Israel Med. Ctr.,
25 University Hospital, and United
Hospitals Medical Ctr., Newark, and
VA Medical Center, East Orange
(Endocrinology Section. AMNJ)
5 Medical Grand Rounds
9:30 A.M.— Newark Beth Israel
Medical Ctr.
(Endocrinology Section. AMNJ)
5 Psychosocial Care and
Unorthodox Cancer Therapies
4-6 P.M. —Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
6 Medical Grand Rounds
1 1 :30 A.M.— University Hospital,
Newark
(Endocrinology Section. AMNJ)
6 Renal Conferences in Nephrology
20 4-5 P.M. —University Hospital.
Newark
(Nephrology Society of NJ and
Nephrology Section, AMNJ)
1 2 Nutritional Support of
Hospitalized Patients
1 9 The Conditioning of Athletes
1 1 A.M.— St. Joseph's Hospital and
Medical Center, Paterson
(St. Joseph's Hospital and AMNJ)
1 3 Controversies in the Management
of Otitis Media
8-9:30 A.M.— Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
17 Laser Treatment of Massive
Gastrointestinal Hemorrhage
1 1 A M - 12 noon — Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
17 Renal Osteodystrophy
4-5 P.M. —Academic Health Science
Ctr., New Brunswick
(UMDNJ -Rutgers Medical School
and AMNJ)
1 8 Substance Abuse and Misuse
8:30 A.M.- 1 P.M.— Medical Society of
New Jersey, Lawrenceville
(NJ State Department of Health.
MSNJ. and AMNJ)
1 8 Dermatological Conference
6-9 P.M. —Rutgers Community
Health Plan, 57 U.S. Hwy. # 1 , New
Brunswick
(UMDNJ and AMNJ)
1 9 Perception of Pulmonary Lesions
1:30-5 P.M. —Saint Barnabas
Medical Ctr., Livingston
(Saint Barnabas Medical Ctr. and
AMNJ)
24 How Scientific Is Modem
Medicine?
7:30-8:30 P.M.— Ramada Inn, Exit
135, Garden State Parkway
(Nephrology Section of NJ and
AMNJ)
26 Renal Hemodynamics of
Hypertension
1 1 A.M.- 12:30 P.M. —St. Joseph’s
Hospital, Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
26 Regional Hospital Meeting
8-10 P.M. —Overlook Hospital,
Summit
(NJ Gastroenterological Society
and AMNJ)
May
1 Strokes, C.V.A.— Post and Rehab
Care
1 1 A.M. 12 noon — Greystone Park
VOL. 81— NUMBER 3— MARCH 1984
241
The Academy of Medicine of New Jersey
The Medical Society of New Jersey
The N.J. State Department of Health
present a symposium on
"SUBSTANCE ABUSE AND MISUSE’"
on
WEDNESDAY, APRIL 18, 1984
9:00 A. M. -1:00 P.M.
at
MSNJ HEADQUARTERS BUILDING
Lawrenceville, N.J.
The program will include presentations by nationally promi-
nent speakers on current concepts in the diagnosis and treat-
ment of substance abuse disorders, update on cocaine abuse
and prescription drug abuse as well as other pertinent topics.
The program is designed for physicians and all other health
care providers who have encountered or do encounter any of
these problems in their professional work.
For further information, please contact:
EXECUTIVE OFFICES
of New Jersey
The Academy of Medicine
New Jersey
Two Princess Road
Lawrenceville, NJ 08648
Phone: (609) 896-1717
of
Update in Occupational Medicine
Jefferson Medical College
Department of Medicine
May 1=3, 1984
18 Hours Category I
AMA Continuing Education Credit
Fee: $125.00 per day or $325.00 for full 3 days
Topics to be included:
Biological Monitoring, Health Promotion
Occupational Pulmonary Diseases and
Ergonomics
To obtain a brochure and enrollment form please
contact:
Cynthia Papaleo
Department of Medicine
Jefferson Medical College
1025 Walnut Street
Philadelphia, PA 19107
(215) 928-8787
APRIL
4/3-10/16
MAY
NftJ
Post-Graduate
Medical School
4/26-4/28
f
5/3-5Z5
5/10-5/13
5/19-5/20
5/19-5/20
5/19-5/20
JUNE
6/4-6Z6
6/4
6/5-6Z9
6/11-6/15
6/23 & 6/24
6/25-6/28
AUGUST
8/27-8/31
FOR INFORMATION
Emergency Medicine Board Review
(Tuesdays, 4-7 P.M.)
Update in Dermatology
The Medicolegal Autopsy
CT of the Spine (Grand Hyatt Hotel)
Review of Basic Sciences in Urology
Proficiency in Cytopathology
Practical Management of Gynecologic
Endocrine Disorders and Infertility
Obstetrical Ultrasound
Interventional Radiology and Digital Imaging
Computed Tomography
Head to Toe with MRI
Emergency Medicine
Chymopapain I & II
(2 intensive 1 day sessions)
Pediatric and Adolescent Medicine
Radiation Physics and Biology
NYU Post-Graduate Medical School
550 First Avenue, New York, N.Y. 10016
(212) 340-5295 (24 hr. service)
Jefferson
Medical College
of
Thomas Jefferson University
presents
2ND ANNUAL UPDATE IN INTERNAL MEDICINE
May 16-18, 1984
at
The Hershey Philadelphia Hotel
A three day intensive symposium sponsored by the
Department of Medicine, Jefferson Medical College,
1 025 Walnut Street, Philadelphia, Pennsylvania.
/?A(CME^ app roved : 20 credit hours in Category I
Willis C. Maddrey, M.D. Program Director
John H Martin, M.D Associate Director
A registration fee of $375.00 includes course syllabus,
continental breakfasts, coffee breaks, luncheons and a reception-dinner.
For information and registration,
call the Office of CME at (215) 928-6992.
242
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
2 Medical Grand Rounds
II 1:30 A.M.— VA Medical Center,
East Orange
(Endocrinology Section, AMNJ)
2 Nephrotoxicity of Common Drugs
1:30-2:30 P.M. —Essex County
Hospital, Cedar Grove
(AMNJ)
2 William P. Burpeau Award Dinner
and Memorial Lecture
6:30 P.M.— The Manor, West Orange
(Urology Section. AMNJ)
2 Occupational Medicine for the
Primary Physician
30 Cancer Emergencies
1 :30-2:30 P.M. —Rutgers
Community Health Plan, 57 U.S.
Hwy. #1, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
2 Endocrine Conferences
9 3:30-5 P.M.— Rotates between
16 Newark Beth Israel Medical Ctr„
23 University Hospital, Newark, and
30 United Hospitals Medical Ctr.,
Newark, and VA Medical Ctr., East
Orange
(Endocrinology Section, AMNJ)
3 Fever of Unknown Origin in the
1980s
24 Carcinoma of the Colon
1 1 A.M.— St. Joseph's Hospital,
Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
3 Recurrent Abdominal Pain
9 AM.— Freehold Area Hospital
(AMNJ)
3 Medical Grand Rounds
9:30 A.M.— Newark Beth Israel
Medical Ctr.
(Endocrinology Section. AMNJ)
3 Chemotherapy
4-6 P.M.— Institute for Medical
Research, Copewood Street,
Camden
(Institute for Medical Research and
AMNJ)
3- 218th Annual Meeting
6 Resorts International, Atlantic City
(Medical Society of New Jersey
and AMNJ)
4 Medical Grand Rounds
1 1:30 A.M.— University Hospital,
Newark
(Endocrinology Section, AMNJ)
4 Renal Conferences in Nephrology
18 4-5 P.M. — UMDNJ-University
Hospital, Newark
(Nephrology Society of NJ and
Nephrology Section. AMA)
8 Principles of Hyperalimentation
in Trauma Patients
7-9 A.M.— Hackensack Medical
Center
(Hackensack Medical Center and
AMNJ)
15 Newer Concepts in CPR
1 2:00 noon— St. Maiy’s Hospital,
Orange
(AMNJ)
1 5 Drugs and Water Metabolism
4-5 P.M. —Academic Health Science
Ctr., Rm. 393, New Brunswick
(UMDNJ and AMNJ)
27
15
Renal Hormone Resistant States
9-
7-8 P.M — Ramada Inn, Clark
(Nephrology Society of NJ and
AMNJ)
13
15
AIDS/Herpes
29
Clinical Treatment of Headache
1 1 A.M.- 12 noon — Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
11
Hospital and AMNJ)
11
16
Drugs, Alcohol, and Pregnant
Women
8:30 A.M.- 3:15 P.M.— Monmouth
Medical Ctr., Long Branch
(Div. of Alcoholism, NJ State Dept.
of Health and AMNJ)
16
16
Dermatological Conferences
6-9 P.M. —Rutgers Community
Health Plan, 57 U.S. Hwy. # 1 , New
Brunswick
(UMDNJ-Rutgers Medical School
18
and AMNJ)
25
16
Modern Medical Genetics
23
Diseases of Mucous Membrane
10:30-12 noon— St. Maiy’s
Hospital, Passaic
(St. Mary’s Hospital and AMNJ)
19
17
Newer Concepts in Sarcoidosis
5-6:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
Clinical Concerns in
Hemodialysis Patients
May
o
18
8:15 A.M.- 5 P.M.
z
19
8 A.M.- 1 P.M.— New York Hilton
Hotel, New York City
(Nephrology Society of NJ and
AMNJ)
30
Gastrointestinal Bleeding
10:30 A.M.- 12 noon— St. Mary’s
Hospital, Passaic
(AMNJ)
2
16
30
30
Hepatic Metabolic Complications
of Alcoholism
1-2:30 P.M.— VA Medical Ctr., Lyons
Bldg. 93
3
10
17
31
(VA Medical Ctr. and AMNJ)
31
How To Live To Be 100
1 1 A.M.— St. Joseph’s Hospital,
Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
4
NEUROLOGY/PSYCHIATRY
11
Apr.
18
2
Identity Disorder Versus
25
Borderline Personality
8:15-10:30 P.M.- 5 Fairfield St.,
Montclair
(Essex Psychiatric Seminar and
AMNJ)
7
5
Behavior Medicine and
Biofeedback
7
12
Treatment Issues of the Depressed
14
Woman
21
19
Cross-Cultural Psychiatry
12 noon-1 P.M. —Carrier
28
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
9
6
Psychiatric Lecture Series
13
1:30-5 P.M. —Trenton Psychiatric
Hospital
(Trenton Psychiatric Hospital and
AMNJ)
Developmental-Behavioral
Disorders: Update 1984
Glenpointe Hotel, Teaneck
(Hackensack Medical Center and
AMNJ)
The Sleepless Patient
9: 1 5 A M.- 4:30 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
Update in Psychosomatic
Medicine
2-5 P.M., 7-9 P.M.— Stony Hill Inn,
Hackensack
(North Jersey Psychiatric Society
and AMNJ)
Principles of Child Psychotherapy
8:30- 1 0:30 P.M — 30 1 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
Group Therapy
2-3 P.M.— Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
Controversies and Pitfalls in
Modern Sex Therapy
5-6:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
Epilepsy-Classification and New
Treatment
10:30 A.M.- 12 noon — St. Mary's
Hospital, Passaic
(AMNJ)
Group Therapy
2-3 P.M.— Ancora Psychiatric
Hospital
(Ancora Psychiatric Hospital and
AMNJ)
The Hypochondriacal Patient
Adolescents and Families with
Drug and Alcohol Problems
Medication Treatment of Phobias
ECT: Sine v Pulse Wave and Other
New Developments
12 noon-1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
Psychiatric Lecture Series
1:30-5 P.M. —Trenton Psychiatric
Hospital
(Trenton Psychiatric Hospital and
AMNJ)
Effect of Porno Pictures on Sexual
Compulsion of a 5 -Year-Old Child
8:15-10:30 P.M.— 9 Marquette
Road, Montclair
(Essex Psychiatric Seminar and
AMNJ)
Psychotherapies
1-3 P.M. —Ancora Psychiatric
Hospital
(Ancora Psychiatric Hospital and
AMNJ)
Convulsive Seizures
1 -2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
VOL. 81— NUMBER 3— MARCH 1984
243
ACUPUNCTURE IN CLINICAL PRACTICE
N Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
March 23-25, 1984 and again the weekend of May 25-27, 1984
at the Barbizon Plaza Hotel, New York City. Co-sponsored by
the International College of Acupuncture & Electro-Therapeu-
tics, its official journal (published by Pergamon Press) the Heart
Disease Research Foundation and the Neuroscience Dept, of
Long Island College Hospital, Pharmacology Dept, of The Chi-
cago Medical School. Also eligible for AMA/CME credit. For
information, contact Y. Omura, M.D., ScD., 800 Riverside Drive
(8-1), NYC 10032. Tel: (212) 781-6262 or (212) WA8-0658, or
Saul Heller, M.D., Tel: (212) 838-7514.
TAX PREPARATION AND PLANNING
• Individual, Partnership, Corporate, Business, Estate
Services
• Expert Services
• Federal, Any State, Foreign Taxes of any type
• All Year Service
• Audit Representation
• Tax Planning and Reduction
• In Home or In Office Service
H. Michael Zukowski
(201) 945-8443
Want to expand your practice?
we are
SPECIALISTS
in
PUBLIC RELATIONS
FOR THE MEDICAL PROFESSION
for a confidential interview call —
(201) 531-7080
phyllis kessel associates
780 West Park Avenue, Oakhurst, N.J. 07755
Doctors: Write your own prescription
to cure insurance pains . . .
Prescription
Prescription
Name MSNJ Member
X
Name
Address
MSNJ Group
Blue Cross/Blue Shield
Major Medical and
Dental Insurance
that provides:
- Flexible plans
- Comprehensive benefits
- Low, competitive rates
- Centralized Administration
Designed and Administered by
(DONALD F SMITH (V ASSOCIATES)
Phone
Please send more information
on the MSNJ
□ Blue Cross/Blue Shield Program
□ Major Medical Program
□ Group Dental Program
Return to:
Donald F. Smith & Associates
One Airport Place, Route 206 North
P.O. Box 2197,
' Princeton, New Jersey 08540
| (609) 924-8700, (201) 622-6046
244
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1 5 Adolescent Health and Illness
16 9 A.M.- 4:30 P.M— Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
1 7 Aspects of Manic-Depressive
Illness
8-10 P.M.— Hackensack Medical Ctr.
(NJ Psychoanalytic Society and
AMNJ)
2 1 Principles of Child Psychotherapy
8:30-10:30 P.M.- 301 Broad St.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
22 Family Therapies
1-3 P.M.— Ancora Psychiatric
Hospital
(Ancora Psychiatric Hospital and
AMNJ)
OBSTETRICS/GYNECOLOGY
Apr.
1 Contraception Today: Improving
the Results, Reducing the
Concerns
9 A.M.- 12 noon— Princeton
Scanticon Conference Ctr.,
Princeton
(UMDNJ and AMNJ)
PATHOLOGY
Apr.
1 1 Pathology Grand Rounds
10:30 A.M.-12 noon— St. Mary’s
Hospital, Passaic
(St Mary's Hospital andAMNJ)
1 2 Radio-labeled Antibodies for
Cancer Detection and Therapy
4-6 P.M.— Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
May
9 Pathology Grand Rounds
10:30-12 noon— St. Mary’s
Hospital, Passaic
(St Mary's Hospital andAMNJ)
PEDIATRICS
Apr.
5 Hematonia and Proteinuria in
Children
9 AM.— Freehold Area Hospital
(AMNJ)
16 Pediatric Lecture Series
12 noon-1 P.M.— The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
25 Pediatric Allergy
10:30 AM.- 12 noon — St. Mary’s
Hosptial, Passaic
(St Mary's Hospital andAMNJ)
May
10 Pediatric Malignant Diseases
4-6 P.M.— Institute for Medical
Research, Copewood Street,
Camden
(Institute for Medical Research and
AMNJ)
18 Changing Concepts in the
Treatment of Seizures
8-9:30 A.M.— Overlook Hospital,
Summit
(Overlook Hospital andAMNJ)
2 1 Outcome of High-Risk Infants
12 noon-1 P.M.— The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
RADIOLOGY
Apr.
7 Real-Time, Cross-Sectional
8 Sector Scanning
9 A.M.- 5 P.M.— Center for Health
Affairs, Princeton
(The National Foundation for Non-
invaslve Diagnostics andAMNJ)
12 Invasive Fetal Therapy
8:30-9:30 P.M.— Saint Barnabas
Medical Ctr.
(New Jersey Institute of Ultrasound
in Medicine andAMNJ)
18 Pathogenesis, Diagnosis, and
Management of Type II Diabetes
1-2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center andAMNJ)
19 Radiology Meeting
7:30-10 P.M.— Saint Barnabas
Medical Ctr., Livingston
(Radiological Society of NJ and
Diagnostic Radiology Section,
AMNJ)
26 Radiation Therapy: Current
Practice and Future Potential
4-6 P.M.— Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research and
AMNJ)
May
16 Dinner Meeting
6:30 P.M. —The Manor, West Orange
(Radiotherapy Section, AMNJ)
17 Combined Meeting
7:30-10 P.M.— Saint Barnabas
Medical Ctr., Livingston
(NJ Institute of Ultrasound,
Radiological Society of NJ, and
Diagnostic Radiology Section,
AMNJ)
24 Forensic Radiology
1:30-5 P.M.— Saint Barnabas
Medical Ctr., Livingston
(Saint Barnabas Medical Ctr. and
AMNJ)
SURGERY
Apr.
4 In and Out Surgery
10:30 AM.- 12 noon— St. Maiy’s
Hospital
(AMNJ)
4 Surgical Departmental
1 1 Conferences
18 8:30 A.M.- 10 A.M.— Rutgers Medical
25 School, New Brunswick
(UMDNJ and AMNJ)
1 0 Current Approach to Management
of Thromboembolism
7-9 A.M.— Hackensack Medical
Center
(Hackensack Medical Center and
AMNJ)
May
2 Surgical Departmental
9 Conferences
16 8:30-10 A.M.— Rutgers Medical
23 School, Medical Education Bldg.,
30 New Brunswick
(UMDNJ and AMNJ)
16 Common Outpatient Surgical
Problems
1 :30-2:30 P.M.— Community Health
Plan, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
30 Surgical Nutrition
I -2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital andAMNJ)
SURGICAL SPECIALTIES
Apr.
5 Vascular Surgical Rounds
12 4-5 P.M. —Rutgers Medical School,
19 New Brunswick
26 (UMDNJ and AMNJ)
6 Second Annual
Meeting— Delaware Valley
Vascular Society
8 Caesars Boardwalk Regency,
Atlantic City
(Delaware Valley Vascular Society
and UMDNJ)
7 9th Annual Orthopaedic
Symposium
8 AM.— UMDNJ-Rutgers Medical
School Newark
(AMNJ)
1 1 Yag Laser Use In Ophthalmology
1-2:30 P.M.— Christ Hospital, Jersey
City
(Christ Hospital andAMNJ)
1 8 Biliary Tract Surgery
10:30a.M.- 12 noon— St. Mary’s
Hospital, Passaic
(St. Mary's Hospital andAMNJ)
26 Glaucoma: A Compendium of
Diseases
8-10 P.M.— Bergen County Medical
Society, Hackensack
(Med, Women's Assoc. andAMNJ)
May
3 Vascular Surgical Rounds
10 4-5 P.M.— Rutgers Medical School,
17 Medical Education Bldg., New
24 Brunswick
31 (UMDNJ and AMNJ)
MISCELLANEOUS
Apr.
3 Computers in Medicine
I I A.M.- 12 noon— Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital andAMNJ)
May
1 Computers in Medicine
7:30 P.M.— Burdette Tomlin
Mem. Hosp., Cape May Court House
(AMNJ)
1 0 Patient Advocacy Issues Two
Years Later
12 noon-1 P.M — Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
VOL. 81— NUMBER 3— MARCH 1984
245
WORD
TO THE
WHYS
WHYAMA?
- - » sassaja
cal Educator .hrough^ ts
AMA.
WHY AMA? The AMA Pr0^!iSse\?d?rgut?s°uesrn
Ssfssislss='=
TO Join. Contact CWcW.
SSSSJSSSX.. (312) 251-61*
M
O/cM-
246
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Letters to the
Editor
Pulmonary Edema
Complicating Epiglottitis;
Temporary Vocal Cord
Paralysis; Total
Mastectomy versus Partial
Mastectomy and Radiation
Therapy; Amyloidosis
Pulmonary Edema
Complicating Epiglottitis
November 22, 1983
Dear Doctor Krosniek:
Our attention was drawn to the
article by Dr. Blankson (November
1983) on pulmonary edema com-
plicating epiglottitis. We would like
to comment that although the com-
plication is interesting from a
pathophysiological point of view this
should not distract the reader from
appreciating the fact that mis-
management of the acute airway
problem probably led to the develop-
ment of the pulmonaiy edema.
Where the diagnosis of epiglottitis
is suspected the only foreign body
which should be inserted into the
mouth would be a cautiously in-
serted laryngoscope under con-
trolled anesthetized conditions im-
mediately prior to intubation. The
route of intubation following
pharyngo-laryngeal inspection
should be oral, initially, and only
after a satisfactory orotracheal air-
way has been established should the
substitution of a nasotracheal tube
be considered.
Having to resort to establishing an
airway by emergency tracheotomy
would appear to indicate the occur-
rence of serious hypoxic-obstructive
problems, which makes the develop-
ment of the subsequent complica-
tion no surprise. The rapid resolu-
tion of the pulmonary edema, we be-
lieve, would support this contention,
(signed) W. Eric Scott, M.D., Head
Division of Critical Care Medicine
Cooper Hospital/
Univ. Medical Center
Carolyn Bekes, M.D.
Director, Intensive Care Unit
Cooper Hospital/
Univ. Medical Center
December 9, 1983
Dear Doctor Krosniek:
I have read with much interest the
letter of Dr. Scott and Dr. Bekes in
reply to my article on pulmonary
edema complicating epiglottitis. It is
quite pretentious of them to suggest
that the pulmonary edema may have
been caused by mismanagement! In
the first place, I do not know where
they got this impression from. In the
second place, they are asserting by
their claim that the 5 to 6 percent
of epiglottitis that develops
pulmonary edema is due to mis-
management. They either may not
be familiar with the entity I de-
scribed or have chosen to ignore it
since it was first described in 1977.
As a matter of fact, some authors
have proposed that this type of
pulmonary edema is caused by the
relief of intrapulmonary pressure by
the endotracheal intubation.
The duration of treatment of non-
eardiae pulmonary edema cannot be
taken as proof of the cause of the
edema. The short duration of treat-
ment of my patient is no proof of
anything, except the elimination of
the obstruction and the concomi-
tant hypoxia which together, I be-
lieve, may cause the pulmonary
edema of airway obstruction.
The patient in my report was not
mismanaged and pulmonary edema
due to upper airway obstruction ex-
ists. I suggest to Dr. Scott and Dr.
Bekes that they consult the referen-
ces to the original article.
(signed) Victor N. Blankson, M.D.
Temporary Vocal Cord
Paralysis
December 15, 1983
Dear Doctor Krosniek:
On December 13, 1983, I exam-
ined the patient with the temporary
vocal cord paralysis (J Med Soe NJ
80:841, 1983).
On indirect laryngoscopy, he
moves both cords well. I hope this is
an adequate reply to Dr. Lawrence J.
Pizzo’s query, and we thus establish
definitely the temporary nature of
the left vocal cord paralysis.
(signed) Nicholas J. Demos, M.D.
Total Mastectomy v
Partial Mastectomy and
Radiation Therapy
December 19, 1983
Dear Doctor Krosniek:
It now is without doubt that lump-
ectomy and irradiation are valuable
options for women who have breast
cancer. Reports and results con-
firmed the earlier nonrandomized
eases of breast cancer treated by
lumpectomy (partial mastectomy)
and radiation. Dr. Vera Peter’s re-
sults regarding her work were
outstanding. Pierquin’s series was
likewise excellent and every phy-
sician knows about Veronesi's re-
port on lumpectomy and radiation
versus mastectomy. Dr. Heilman’s
persistence in giving the patients an
alternative treatment has paid. Most
recently, preliminary results from
the National Cancer Institute like-
wise are very promising.1 The NCI
(National Cancer Institute’s ran-
domized trial) to date has collected
120 patients: 60 patients had modi-
fied radical mastectomy and 60 pa-
tients had lumpectomy and local
radiotherapy. Dr. Samuel Broder, Di-
rector of the Division of Cancer
Treatments Clinical Oncology Pro-
gram, stated that “data collected to
date (although too early for a final
conclusion) suggest that radio-
therapy will prove to be equivalent to
mastectomy in terms of disease-free
survival with the added feature of
excellent cosmetic results.”
All practicing physicians should
know that, at present, mastectomy
does not have to be done to be able
to achieve local control. Surgeons in
particular should have an open
mind regarding the initial manage-
ment of early breast cancer. They
should realize that local control
could be achieved by doing less than
modified radical mastectomy. Sur-
geons have to know that micro-
scopic disease can be eradicated bv
radiation given the proper dose.
VOL. 81— NUMBER 3— MARCH 1984
247
The advantage of lumpectomy and
radiation over mastectomy obvious-
ly is cosmetic. We now know that
lumpectomy and radiation are not
better than mastectomy nor the lat-
ter better than the former. Surgeons
should do their best to follow the
NSBP Protocol 06 recommendation
for the direction of the incision used
for tumorectomy.2 This Protocol also
recommends a separate incision for
the axillary surgery. If one incision
is done for excision of an upper
outer quadrant mass, this will result
in lateral deviation of the breast.
Likewise, radiation oncologists have
to pay meticulous attention to the
treatment plan and technique for
radiating an intact breast. If not, we
might pass up a veiy good op-
portunity to give these patients a
very viable alternative.
(signed) Roy C. Cabrera M.D.
Louis E. Schwartz, M.D.
REFERENCES
1 . The Clinical Cancer Letter, October
1983.
2. Bedwinek JM: Treatment of stage 1
and II adenocarcinoma of the breast by
tumor excision and irradiation.
Amyloidosis
December 20, 1983
Dear Doctor Krosniek:
I read with great interest in the
December issue the article on
amyloidosis by Drs. Zauber and
Wallen. It is an excellent review of
the complex and increasingly rel-
evant disease group. The summary
of the chemical nature of the beta
fibrilloses especially is enlightening.
At one point, the authors state:
“Amyloid formation not only re-
quires a protein with intrinsic
amyloidogenic properties, but prob-
ably involves modification of a
precursor protein.” The statement is 1
somewhat confusing, as it describes
two different types of amyloidosis. In
primary amyloid, it is an amyloido-;
genic protein— the variable portion
of light chain — whereas in the sec-
ondary form, modification of a nor-
mal precursor, SAA, to amyloido-
genic AA, that leads to amyloid for-
mation. In addition, prealbumin, a
normal circulating protein, appears
to participate in amyloidogenesis in
the increasingly recognized her-
edofamilial forms of the disease.
Senile amyloidosis, especially
cardiac and cerebral, remain poorly
understood. The nature and
pathogenesis of amyloidosis con-
tinue to be the subject of intense
research effort.
(signed) John Varga, M.D.
Boston University Medical Center
i
248
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
BOOK REVIEWS
Basic and Clinical
Endocrinology; Emergency
Medicine; Fundamentals of
Family Medicine; Health
and Human Values; Male
Reproduction and Fertility;
Medicine for the Practicing
Physician; Practical
Infectious Diseases
Basic and Clinical
Endocrinology
F.S. Greenspan and P.H. Forsham.
Lange Medical Publications, Los
Altos, CA 1983. Pp. 646. ($25)
In this book, we find a selected
discussion presented by many con-
tributing authors. The text covers a
wide panorama of basic endocri-
nology, laced with pathophysiologic,
clinical diagnostic, and therapeutic
information. The reader will uncover
information that is well known as
well as information that is con-
sidered investigational; both with
up-to-date commentary. Besides the
various glands examined individu-
ally, we find such topics as pediatric,
pubertal, and pregnancy en-
docrinology; gut regulatory peptides;
lipoprotein metabolism; obesity; ec-
topic hormone production; hor-
mones and cancer; multiple en-
docrine gland syndromes; and low
T3 and low T4 syndrome.
The information is well presented
and the text is nicely written. A few
editing errors, such as in the thyroid
section (figure 7-3, page 131), may
be confusing to the medical student.
The wealth of pertinent information
is valuable to the beginner and the
I practicing endocrinologist. Ade-
quate references are quoted follow-
ing each chapter for those interested
in further specific discussion and
investigation. The figures, tables,
I
and graphs are helpful for under-
standing and formulation of
diagnostic and therapeutic method-
ology—the backbone of clinical en-
docrinology. I congratulate the
authors on their presentation and
organization of the voluminous ma-
terial and look forward to the prom-
ised second edition in two years.
Mark M. Singer, M.D.
Emergency Medicine
Harold L. May, M.D., (ed). New York,
NY, John Wiley & Sons, 1984. Pp.
1,062. Illustrated.
This hard-covered text of over
1,000 pages appears to have been
developed for teaching purposes in
a medical school or emergency medi-
cine residency program, or as a ref-
erence book in a hospital library.
The text is written in great detail
and includes postemergency treat-
ment. It is well-illustrated wherever
necessary. At the end of each
chapter there are many biblio-
graphic listings for suggested read-
ings in the various subjects in each
chapter.
There are 79 contributors, of
which 86 percent are medical school
instructors and the balance of the
contributors write about specific
specialties. There are subjects dis-
cussed that go beyond the emer-
gency treatment and to the followup
treatment. There is a possibility that
some readers may question a spe-
cific subject, especially if the individ-
ual reader may have had much ex-
perience working in a hospital
emergency department. An example
of this is the statement, “Hyper-
tension emergencies are rare. They
occur in fewer than 1 percent of pa-
tients with high blood pressure.” Na-
tional statistics have shown that
there are 30,000,000 individuals in
the United States with hyper-
tension.
It is interesting to note that 70
percent of the contributors are in-
structors in an eastern medical
school. Jack R Karel, M.D.
Fundamentals of Family
Medicine
Robert B. Taylor, M.D., (ed). New
York, NY, Springer-Verlag, 1983. Pp.
488. Illustrated. ($34.50)
This paperback volume represents
an extract from a more complete
work entitled. Family Medicine:
Principles and Practice, and is in-
tended for the medical student. It
presents a broad overview of the
range of courses of the medical
school curriculum from the clinical
view of the well-trained family physi-
cian, addressed particularly to the
development of the behavior, con-
cepts, and skills necessary to the
specialty. Starting with the basic
family doctor relationship, the need
for a family physician, interfamily
dynamics in health and disease, and
interesting case descriptions of the
physician’s role, this book explores
such topics as the natural history of
disease, comprehensive and con-
tinuous care, care at various stages
of the family’s life cycle, and normal
changes with aging.
There are interesting chapters on
counseling during periods of death
and bereavement (including hos-
pice), premarital, marital, sexual,
genetic, nutrition, and health main-
tenance. Brief chapters on problem
solving, physical diagnosis, and use
of the laboratory are presented as
introductions to these subjects, as
are electrocardiography and newer
modes of diagnostic roentgenology.
References to the medical litera-
ture are presented after each
subchapter, and a subject index is at
the end of the book.
This volume, as part of the com-
plete work, appears to be a valuable
student textbook for those wishing
to understand the broad discipline
of family medicine and for those
contemplating residency training in
the specialty.
Joseph Peyser, M.D.
Health and Human
Values: A Guide to
Making Your Own
Decisions
Frank Harrow John Burnside, Tom
Beauchamp. New Haven, CT, Yale
University Press, 1983. Pp. 194.
($24.95)
This small book provides an in-
troduction for a general audience to
complex health issues in the hope
that its readers will be better
prepared to cope in an era of values
transition. The authors (an
Episcopal priest, an internist, and a
philosopher) collaborate to provide a
variety of perspectives. Their style is
lucid and focuses on the following
issues: moral decision making,
euthanasia abortion, health care
VOL. 81— NUMBER 3— MARCH 1984
249
and distributive justice, truth telling
and informed consent, determina-
tion of death, and genetic engineer-
ing.
Each chapter includes illustrative
cases and an excellent selection of
annotated references. The text is
supplemented by three inexpensive
paperbacks which give additional
background material; these include
a leader’s manual, a digest of ex-
cerpted landmark legal decisions,
and an audio-visual resource man-
ual.
Preparation of these texts was
sponsored by the Society for Health
and Human Values of the United
Ministries in Education. These or-
ganizations aim to provide the gen-
eral public with reliable information
so that citizens can make their own
informed decisions. Towards this
end, this book succeeds admirably
and it should also prove to be useful
and thought provoking for the
interested professional as well as the
layperson. Michael Nevins, M.D.
Male Reproduction and
Fertility
Andres Negro-Vilar (ed). New York,
NY, Raven Press, 1983. Pp. 390.
Although the chapters of this
compendium are not in physiologic
order, it drives home a point regard-
ing the complexity of male repro-
ductive neuroendocrinology (an-
drology). The first chapters review in
detail the deleterious effects of hy-
perprolactinemia in male fertility.
Hormonal release mechanisms from
the hypothalamic-pituitary system
are addressed including the
adrenergic-cholinergic receptor
areas and the effects of gamma
aminobutyric and hydroxybutyric
acids. It is interesting to note that
calcium channel blockers (when lo-
cally applied) can depress prolactin
release from rat hypothalamus.
Thus, we may wonder about the re-
productive/sexual implications of
the recently used calcium channel
blockers for coronary spasms.
This book also reiterates the im-
portance of hormonal circadian
pubescent-senescent rhythmic male
fertility pattern and elucidates the
harmful effects in the male offspring
following maternal exposure to
marijuana and alcohol. The
biochemistry of prostate protein,
kinases, and its androgenic action
are discussed with the possible use
of buserelin — an LHRH agonist as a
treatment alternative for prostate
CA.
One of the exciting chapters deals
with the newest medical fertility
treatment innovations of idiopathic
normogonadotropic oligozoo-
spermia. The first therapy is
kallikrein and if no response after 3
months, the following drugs are sug-
gested at 3, 6, and 12 month inter-
vals, i.e. mesterolone, MHG + HCG,
tamoxifen, and artifical insemina-
tion. Finally, the discussion of male
inhibitory material (MIM) as the
possible cause of autoimmune ster-
ility is a challenge to the fertility
physiologists.
This text is research oriented;
however, the clinical reproductive
endourologists, obstetricians, and
immunologists would benefit most
in the assessment of male infertility,
sperm cryopreservation, and
artificial insemination of different
types of sperm origin and popu-
lation. J.F.J. Leyson, M.D.
Director of Sex Clinic
VA Medical Center, East Orange
Medicine for the
Practicing Physician
J. Willis Hurst (ed). Woburn, NLA
Butterworth Publishers, 1983. Pp.
1,969. Illustrated, ($80)
What a delight to pick up a new
textbook on medicine for the prac-
ticing physician — with a new ap-
proach, a new format, and a new de-
sign for teaching, reading, and re-
view. And there is even a surprise:
the paragraph at the end of many of
the subjects discussed describes
“cost containment.” Quality as-
surance has arrived to stay and be-
come an active part in teaching.
Today’s physician must learn the
reasonable cost of health care for the
patient, both in the office and dur-
ing hospital stay.
Medicine for the Practicing Phy-
sician is massive in size. Included
are indepth lectures by contributors
from the faculty of Emory University
School of Medicine and from sur-
rounding teaching hospitals in the
Atlanta, Georgia area
This edition is the beginning of a
new way of thinking and collection
of thoughts and ideas in the se-
quence of learning and study of
medicine. The lesson plan composes
diagnostic criteria clinical evalu-
ation both subjectively and objec-
tively: plans for diagnostic and
therapeutic approach; followup pa-
tient care after hospital release; a re-
view of basic science and natural
history of the illness; preventive
care; and the “cost containment"
factor of getting the best and most
efficient cure for the least cost.
The reading is easy; the lectures
are all well composed with adequate
cross-references on every subject.
Chapters are divided into topics
dealing with a particular illness or a
preventive problem. Subjects are re-
viewed by a formidable staff and the
result is gratifying and well done.
As a practicing physician for more
than 30 years, I have seen many new
texts, but never one so skillfully com-
posed for study, review, and learning
both for students as well as estab-
lished practitioners. It is a good in-
vestment for continued medical
education and review.
Harry M. Poppick, M.D.
Practical Infectious
Diseases
Richard D. Meyers, M.D., (ed). New
York, NY, John Wiley and Sons,
1983. Pp. 254. ($14.95)
This small book is one of a series
dealing with all nine medical
subspecialties. Most of the authors
are from the UCLA Medical School.
There are 12 chapters divided into
three parts: common clinical infec-
tions; antibacterial chemotherapy;
and viral infections and viral
chemotherapy. There is an excellent
chapter on legionnaires’ disease
emphasizing the differential diagno-
sis with Streptococcus pneumoniae
and Mycoplasma pneumoniae. On
the other hand, the discussion of
other pulmonary infections is inade-
quate. Also, there are no presen-
tations of many other infections,
such as those from travel, animals,
skin infections, and AIDS. In fact,
this book is little more than what
one would expect from a series of
lectures for medical students.
I cannot recommend Practical In-
fectious Diseases: it would be better
to buy a more complete reference
book on the subject.
Dominic A. Mauriello, M.D.
250
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Obituaries
Dr. David W. Anthony
At the grand age of 90, David
Wesley Anthony, M.D., died on Sep-
tember 25, 1983. A retired member
of our Middlesex County compo-
nent, Dr. Anthony was a 1924 gradu-
ate of Howard University College of
Medicine, Washington, D.C. A family
practitioner. Dr. Anthony was a
member of the American Medical As-
sociation. He was a recipient of
MSNJ’s Golden Merit Award for 50
years of medical service to his com-
munity.
Dr. Israel L. Chanin
Word has been received of the
death of Israel Levick Chanin, M.D.,
a member of our Hudson County
component, on April 10, 1983. Bom
in 1908, Dr. Chanin earned a medi-
cal degree at Lausanne Medical
School, Switzerland, in 1939. Dur-
ing his career. Dr. Chanin was af-
filiated with Jersey City Medical
Center. A member of the American
Medical Association, Dr. Chanin also
served as a medical inspector for the
Board of Health.
Dr. Joseph I. Esposito
At the age of 64, Joseph Irwin
Esposito, M.D., died on December
10, 1983. Dr. Esposito earned his
medical degree at Hahnemann
Medical College, Pennsylvania, in
1951. A family practitioner. Dr.
Esposito served the Hammonton
community since 1952. Dr. Esposito
was a member of our Atlantic Coun-
ty component and of the American
Medical Association. During his ca-
reer, Dr. Esposito was affiliated with
Kessler Memorial Hospital, Ham-
monton.
Dr. Arthur F. Gross
Arthur Franklin Gross, M.D., a
member of our Passaic County com-
ponent, died on September 6, 1983.
Bom in 1900, Dr. Gross received his
medical degree from Seton Hall Col-
lege of Medicine and Dentistry in
1961. An internist. Dr. Gross was af-
filiated with St. Joseph’s Hospital
and Medical Center, Paterson, and
Chilton Memorial Hospital, Pomp-
ton Plains. Dr. Gross was a member
of the American Medical Associa-
tion.
Dr. David Halperin
Word has been received of the
death of David Halperin, M.D., a re-
tired member of our Hudson County
component. Bom in 1908, Dr.
Halperin earned his medical degree
at the University of Maryland School
of Medicine in 1932. During his ca-
reer, Dr. Halperin was affiliated with
Jersey City Medical Center and was
a member of the American Medical
Association.
Dr. George T. Henderson
George T. Henderson, M.D., assis-
tant medical director of Roosevelt
Hospital, Edison, died on December
14, 1983. Dr. Henderson was a mem-
ber of our Middlesex County compo-
nent. Bom in 1921, Dr. Henderson
earned his medical degree at New
York University School of Medicine
in 1945. An anesthesiologist, Dr.
Henderson was affiliated with
Middlesex General Hospital and St.
Peter’s Medical Center, both in New
Bmnswick. He was a Diplomate of
the American Board of Anesthe-
siology, a member of the American
Medical Association, and a Fellow of
the American College of Anes-
thesiologists.
Dr. Nathan Karshmer
A retired member of our Middlesex
County component, Nathan
Karshmer, M.D., died on November
29, 1983. Bom in 1902, Dr.
Karshmer was awarded a medical
degree from George Washington
University School of Medicine,
Washington, D.C.. in 1924. A
gynecologist. Dr. Karshmer was af-
filiated with St. Peter’s Medical
Center and Middlesex General Hos-
pital, both in New Bmnswick. Dr.
Karshmer was a member of the
American Medical Association, and
a Fellow of the American College of
Surgeons, of the American College of
Obstetricians and Gynecologists,
and of the International College of
Surgeons.
Dr. Joseph H. Kler
On November 21, 1983, Joseph
Henry Kler, M.D., died . Dr. Kler was
the author of The Journal's column
entitled, “Medical Philately." Bom in
1902, Dr. Kler earned his medical
degree at the University of Penn-
sylvania School of Medicine in 1928.
During his lengthy career, Dr. Kler
was affiliated with Middlesex Hospi-
tal and St. Peter’s Medical Center,
both in New Bmnswick. Dr. Kler was
a recipient of MSNJ's Golden Merit
Award for 50 years of service to the
community. A member of our
Middlesex County component and of
the American Medical Association,
Dr. Kler was a Diplomate of the
American Board of Otolaryngology
and a Fellow of the American College
of Surgeons.
Dr. George H. Kostant
George Harold Kostant, M.D., a
prominent South Orange derma-
tologist, died on December 1, 1983.
Born in 1916, Dr. Kostant earned
his medical degree at Duke Univer-
sity, North Carolina, in 1940. A
member of our Essex County com-
ponent and of the American Medical
Association, Dr. Kostant was af-
filiated with General Hospital, Irv-
ington, Saint Barnabas Medical
Center, Livingston, and the Veterans
Administration Medical Center,
East Orange. Dr. Kostant was a
Diplomate of the American Board of
Dermatology.
Dr. George Ladas
At the age of 81, George Ladas,
M.D., died on November 23, 1983. Dr.
Ladas was a gynecologist affiliated
with Saint Barnabas Medical
Center, Livingston, and Elizabeth
General Medical Center, for over 50
VOL. 81— NUMBER 3— MARCH 1984
251
years. Dr. Ladas received his medical
degree from Cornell University Medi-
cal College, New York, in 1927. A
member of our Union County com-
ponent and of the American Medical
Association, Dr. Ladas was a recipi-
ent of MSNJ’s Golden Merit Award
for his years of service to the medical
community.
Dr. John B. McCue
John Beebee McCue, M.D., a mem-
ber of our Passaic County compo-
nent, died on November 18, 1983, as
a result of a plane crash. Dr. McCue
was 76 years old. He received his
medical degree from Johns Hopkins
Medical School, Maryland, in 1933.
Dr. McCue retired from active prac-
tice after 50 years of service; he was
a recipient of MSNJ’s Golden Merit
Award. During his career. Dr. McCue
was affiliated with Chilton Hospital,
Pompton Plains, and St. Joseph’s
Hospital and Medical Center,
Paterson. A member of the American
Medical Association, Dr. McCue was
a Diplomate of the American Board
252
of Family Practice and a Fellow of
the American Academy of Family
Practice.
Dr. Louis Meltsner
Louis Meltsner, M.D., a retired
member of our Hudson County com-
ponent, died last year. Dr. Meltsner
graduated from Columbia Univer-
sity College of Physicians and Sur-
geons, New York, in 1923. A radiol-
ogist, Dr. Meltsner retired from prac-
tice in 1975. He received MSNJ’s
Golden Merit Award for his years of
service. A Diplomate of the American
Board of Radiology, Dr. Meltsner was
a member of the American Medical
Association.
Dr. Michael J. Rusin
On December 13, 1983, Michael
Joseph Rusin, M.D., died. Dr. Rusin
was bom in 1917 and earned his
medical degree in 1943 from New
York University School of Medicine.
A family practitioner. Dr. Rusin was
affiliated with General Hospital,
Passaic.
THE JOURNAL OF THE
Dr. Arthur H. Stein
At the untimely age of 50, Arthur
Henry Stein, M.D., died on December
2, 1983. He was chief of medical ser-
vices at Atascadero State Hospital
since 1979 and was previously in
private practice for 26 years. Dr.
Stein graduated from Downstate
Medical College, New York, in 1933.
A member of our Bergen County
component. Dr. Stein was a
Diplomate of the American Board of
Psychiatry and was affiliated with
Englewood Hospital.
Dr. George M. Walters
Word has been received of the
death of George Myron Walters, M.D.,
a retired member of our Middlesex
County component. Bom in 1896,
Dr. Walters received his medical
degree from Syracuse University
Medical School, New York, in 1922.
During his career. Dr. Walters was
affiliated with Rahway Hospital, and
was a member of the American
Medical Association.
MEDICAL SOCIETY OF NEW JERSEY
author Information
Style
Sheet
The Journal is the
official organ of the
Medical Society of New
Jersey. The goals of The
Journal are educational
and informational. All
material published in The
Journal is copyrighted by
MSNJ.
CONTENT
The educational content of each
issue appears as scientific articles,
based on research, original concepts
relative to epidemiology of disease,
and treatment methodology; case re-
ports based on unusual clinical ex-
periences; review articles; clinical
notes, succinct items on some
aspect or new observation or tech-
nique of a case experience; and
special articles, which include evalu-
ations, policy and position papers,
and reviews of nonscientific sub-
jects. Other topics include commen-
tary (critical narration); medical his-
tory; therapeutic drug information;
pediatric briefs; nutrition update:
and an opinion column. Editorials
are prepared by the Editor and by
guest contributors on timely and rel-
evant subjects; editorials are the re-
sponsibility of the author. The Doc-
tors’ Notebook section contains or-
ganizational, informational, and ad-
ministrative items from MSNJ and
from the community. Letters to the
Editor and book reviews are wel-
come and will be published as space
permits. The principal aim in the
preparation of a contribution
should be relevance to diagnosis and
treatment and to education of pa-
tients and professionals. Preference
will be given to professional authors
from New Jersey and to out-of-state
lecturers who submit a suitable
VOL. 81— NUMBER 3— MARCH 1984
manuscript based on a presentation
made in New Jersey.
ASSIGNMENT OF COPYRIGHT
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Me die us:
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2. Dixon WJ, Massey FJ: Introduc-
tion to Statistical Analysis. New
York, NY, McGraw-Hill, 1969, pp.
42-48.
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253
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254
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CLASSIFIED ADVERTISEMENTS
DIAGNOSTIC RADIOLOGIST— Board
certified, trained in general diagnosis,
nuclear medicine, special procedures,
C.T. and ultrasound. Available full or
part-time: group practice or hospital
based; North or Central New Jersey. Can
also provide mobile ultrasound and office
consultation. Reply to Box No. 63,
JMSNJ.
GENERAL PRACTITIONER— Desires in-
dustrial, pharmaceutical or similar po-
sition. Semi-retired, age 55, (201)
545-4339.
. GENERAL SURGEON— Board certified,
wishes to join another surgeon or a
group in area of Monmouth County or
adjoining counties. If interested please
contact Dr. Hasan (201) 972-1584.
INTERNIST— Board eligible internist
wants a hospital/clinic or health center
position in Northern New Jersey. For
further information, write Box No. 67,
JMSNJ.
INTERNAL MEDICINE — Board eligible,
general internist with extensive emer-
gency room experience seeking group
practice of internal medicine or emer-
gency room position. Northern New Jer-
sey area Available July 1984. Please call
(212) 645-4616, Steven Wolinsky, M.D.
Curriculum vitae and references avail-,
able upon request.
INTERNIST— Seeking small group prac-
tice. Internal medicine, IV2 hours from
New York City in NY, CT, NJ. Boston and
NYC University Hospital trained. Boston
University MD Cum Laude, 1981. ABIM
eligible and available July 1984. Contact
Box No. 70, JMSNJ.
OPHTHALMOLOGIST— Board eligible,
July 1984, Board certified Pediatrics
(1982), age 29, desires partnership or
group. Available July 1984. Write Box No.
65, JMSNJ.
PEDIATRIC DLABETOLOGIST/ENDO-
CRINOLOGIST — Seeks association,
partnership with established physician
in New York metropolitan area Please
phone after six 617-738-6205.
PHYSICIAN — Retired, MD, age 60, seeks
part or full time job in South Jersey.
Prefer institutional, outpatient or in-
surance work. Telephone 609-927-7782
or 609-927-1873.
NEEDED DISABILITY EVALUATION
PHYSICIAN— South Jersey area Some
experience in trauma and orthopedic
diagnosis. Part-time with flexible sched-
ule. Hourly stipends. Write Box No. 68,
JMSNJ.
NEEDED FAMILY PHYSICIAN — Board
eligible, for partnership in one of the
largest family practice facilities in New
Jersey. Please send resume to Box No. 69,
JMSNJ.
NEEDED ASSOCIATE— Pediatrician,
board certified; seeks associate, board
certified/eligible, to join well established
practice. Excellent opportunity. Northern
New Jersey near New York City. Write Box
No. 40. JMSNJ.
NEEDED PRIMARY CARE PHYSICIANS
—Private fee-for-service practice in new,
fully equipped suburban offices. All per-
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time for the pursuit of happiness. Reply
to: Neighborhood Doctor Corporation,
901 Long Beach Blvd., Ship Bottom, NJ
08008.
NEEDED RADIOLOGIST— Part time, 2
mornings per week. Ocean County.
Prefer competent retired person. Write
Box No. 62, JMSNJ.
ALLERGY PRACTICE— Allergist
certified or board eligible for Purchase of
very desirable Practice, child and adult.
Central NJ. Write Box No. 47, JMSNJ.
PRACTICE FOR SALE— ENT, estab-
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Phone 215-252-6341.
PRACTICE FOR SALE— Pediatrics. Long
established practice, Vi block from hospi-
tal. Property and equipment. Located in
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Box No. 64, JMSNJ.
PRACTICE FOR SALE OR RENT— Fam-
ily Practice, for sale or rent office and
equipment. Near a 550 bed teaching hos-
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P.M. (201) 681-2566.
EQUIPMENT — 3M 209 copier with auto-
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201-725-6113.
OFFICE SPACE SHARED NEEDED
—Board certified internist desires office
space in Camden County (Cherry Hill,
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Call Dr. Chen (513) 475-4368.
OFFICE SPACE— Professional office to
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area of Bridgewater. Ideal for urologist,
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fessional. Available March or April. 201-
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OFFICE SPACE— Edison, 1,214 square
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Available immediately. Call Dr. Bronstein
(201) 738-8000.
OFFICE FOR RENT— Edison, 1,300
square feet, new building, 1 72 Amboy Av-
enue. Ample parking, no steps. Near
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OFFICE SPACE— Moo restown, NJ. Vic-
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tom medical offices in new building. Ideal
for radiologists, orthopedist, urologist,
general surgeon, industrial physician.
Excellent location and parking. Call (609)
235-2651.
OFFICE FOR RENT— Professional office
for rent, approximately 710 square feet
near Dover General Hospital. Near
Routes 80 and 46. Morris County, NJ.
Telephone (201) 366-2557.
OFFICE SPACE TO SHARE— Mor-
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fully equipped, newly decorated. All util-
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Near public transportation. Available im-
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OFFICE SPACE — North Haledon. Two
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able in professional building close to
Paterson General Hospital. Immediate
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the entire 3000 square foot building.
Free basement storage. Call (201)
427-7500.
FOR SALE— OFFICE SPACE Roselle,
modem 2,400 square feet, 6 treatment
rooms and 4 consultation rooms. On-site
parking. Warinanco Medical Building.
Phone (201) 687-0102.
OFFICE SPACE — Southern New Jersey,
Gloucester Township, Camden County.
Office suite in new medical building for
rent. 1,000 or 2,000 square foot suites
available. Located in rapidly growing,
highly desireable area near several large
hospitals. Ideal for family practice or
specialist. Building to be completed late
1984. Call Dr. Ribatsky 609-227-2221.
OFFICE SPACE — For immediate oc-
cupancy new, modem, energy efficient
rental 500 to 2,000 square feet available
from $5 per foot. 31,000 residents within
three mile radius. Close to Philadelphia
Atlantic City in Central Jersey shore
area Internists and specialities needed.
Ideal for main/satellite office. Call (201)
350-1008.
OFFICE SPACE TO SHARE— Westfield,
central location. Near hospital, fully
equipped, attractively decorated. All util-
ities included. Ample parking available.
Near public transportation. Available im-
mediately. (201) 267-2555.
FOR SALE — Boat. 1982 Sea Ray Sedan
26 foot, all extras. Call (201) 864-7172.
VOL. 81— NUMBER 3— MARCH 1984
255
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(COLLECT) (215) 568-2042
ATTN: LT PAT DAY
256
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Journal
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I
New Jersey
APRIL 1984
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VOL. 81— NUMBER 4— APRIL 1984
257
April 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 766
Officers and Trustees
President
Alexander D. Kovaes, M.D. (Union) Scotch Plains
President-elect
Frank Y. Watson, M.D. (Essex) Glen Ridge
First Vice-President
Ralph J. Fiorettl, M.D. (Bergen) Rochelle Park
Second Vice-President
Edward A. Schauer, M.D. (Monmouth) Farmingdale
Immediate Past-President
Howard D. Slobodien, M.D. (Middlesex) Metuchen
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Douglas M. Costabile, M.D.,
Chairman (1984) (Union) Murray Hill
Frank Campo, M.D. (1984) (Mercer) Trenton
Harry M. Carnes, M.D. (1985) (Camden) Audubon
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
John J. Crosby, Jr., M.D. (1984) Jersey City
Palma E. Formica, M.D. (1984)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney's Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
William Greifinger, M.D. (1984) (Essex) Belleville
John P. Kengeter, M.D. (1984) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Michael R Ramundo, M D. (1984) (Passaic) Clifton
Councilors
First District
(Essex. Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1984) Cranford
Second District
(Bergen. Hudson, Passaic, and Sussex Counties)
Robert A. Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Albert F. Moriconi, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1984) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D'Elia, M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1984) Hackensack
Frederick W. Durham, M.D. (1984) Haddonfield
Palma E. Formica, M.D. (1984) New Brunswick
Karl T. Franzoni. M.D. (1984) Trenton
John S. Madara, M.D. (1984) Salem
Henry J. Mineur, M.D. (1984) Cranford
Myles C. Morrison. Jr., M.D. (1985) Morristown
Howard D. Slobodien. M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Publication Committee
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Wm. A. Dwyer, Jr„ M.D. (Surg)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Heniy R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba, M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa, M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of New
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Printing
Co. Whole number of issues 961. Member’s subscription ($10) is included in Society dues. Rates for nonmembers,
$20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, Two
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and additional
entry office. Copyright 1984 by the Medical Society of New Jersey.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
258
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VOL. 81— NUMBER 4— APRIL 1984
259
The Journal
the Medical
Society of
New Jersey
APRIL 1984
Features
265 Membership Newsletter
276 Professional Liability Commentary
28 1 Editorial
283 Hospital Governing Beards
285 Physician Legal Bulletin
Contributions
29 1 Deaths Related to Narcotics Overdose in New Jersey
E. Feuer, M.D., and J. French, M A, Trenton
297 Computerized Tomography-Guided Percutaneous Needle Biopsy
K.L. Jewel, M.D., Montclair
303 Premenstrual Syndrome: Fact or Fantasy?
M A Pelosi, M.D., Bayonne
311 Rehabilitation of Cognitive Function in Brain-Damaged Persons
I. W. Pollack, M.D., H. Kohn, Ph.D., M.H. Miller, Ph.D., Piscataway
3 1 7 Case Report: Tuberculous Abscess of the Spleen
W.E. Farrer, M.D., and S. Ramamurti, M.D., Elizabeth
320 Case Report: Intrauterine Testicular Torsion
J. Rosenberg, M.D., and M. Zimmerman, M.D., Clifton
322 Pharmacological Basis of Therapeutics: Anticonvulsant Agents
H.M. Geller, Ph.D., Piscataway
325 Pediatric Briefs
RH. Rapkin, M.D., F.C. Behrle, M.D., S.C. Sun, M.D., Newark
Doctors1 Notebook
327 Trustees’ Minutes: February 19, 1984
328 President’s Column, Alexander D. Kovacs, M.D.
329 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
329 MSNJ Auxiliary, Mrs. Gale Way man
330 AMNJ Report, Paul J. Hirsch, M.D.
330 New Members
33 1 Dennis R. Filippone: Maimonides Award Recipient
33 1 Physicians Seeking Location in New Jersey
MSNJ Departments
335 Report of the Nominating Committee
337 CME Calendar
342 Letters to the Editor
344 Book Reviews
346 Obituaries
347 Information for Authors
On The Cover: Photographer
Uand physician, Owen A.
Shteir, M.D., a member of our
Mercer County component,
can be credited with this
scene of Princeton farmlands.
Dr. Shteir is an avid photogra-
pher whose work has been
exhibited in the state.
_ . — i— — ■
I
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
260
Attention: DOCTORS*^
CDfTlPUTER
ana
communicaTion
THOMAS H. GASQUE
Producer
EHPO
convention hall, asbury park, new jersey
april 12*13 *14 *15, 1984 • 10am to 6 pm daily
A Business Products/Services Exposition
W Special Seminars on
COMPUTERIZATION
for the Medical Profession
Hardware ■ Software • Consultation
Special Programs and Seminars scheduled
for Corporate • Small Business • Banking
Education • Legal Professions.
Computer and Communication Expo • Convention Hall, Asbury Park, N.J. 07712 • Tel. 201-776-6260
'OL. 81— NUMBER 4 — APRIL 1984
261
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets —
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING mg mg mg
CAPSULES
The appearance ol
INDERAL L.A
I - I capsules is a registered
' AvPr^t trademark of
Ayerst Laboratories
ONCE-DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE
THERAPY IN ANGINA (PROPRANOLOL HO)
INDERALLA ill
LONG ACTING
CAPSULES
80
mg
120
mg
160
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION. SEE PACKAGE CIRCULAR.)
INDERAL LA brand of propranolol hydrochloride (Long Acting Capsules}
DESCRIPTION, inderal LA is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect. INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients. Jjj
In angina pectoris, propranolol generally redubes the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced incteases in the heafl rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol |
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic
pressure and systolic ejection period The net physiologic effect of beta adrj nergic blockade
is usually advantageous and is manifested during exercise by delayed; onset of painpind
increased work capacity WW .Q-gi
In dosages greater than required for beta blockade, INDERAL also exerts a quinidii i- ~lit<e
or anesthetic-like membrane action which affects t no carrf ac action potentia The signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not beep established Beta-
adrenergic receptors have been demonstrated in the pi at vessels Of the brain.
Beta receptor blockade can be useful in conditions in which, because Of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For'examplefTn patients with Severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement ol unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
ot having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonaliergic Bronchospasm (e.g., chronic bronchitis, emphysema} —
PARENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therai
prior to major surgery is controversial. It should be noted, however, that the impaired ability
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthes
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of bet
receptor agonists and its effects can be reversed by administration of such agents, e.c
dobutamine or isoproterenol. However, such patients may be subiect to protracted seve
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported wr
blockers
DIABETES AND HYPOGLYCEMIA' Beta-adrenergic blockade may prevent the a; t
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes)
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be mo
difficult to adjust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidisr
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptorr
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function test
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bee
reported in which, after propranolol, the tachycardia was replaced by a severe bradycard
requiring a demand pacemaker In one case this resulted after an initial dose of 5 m
propranolol
PRECAUTIONS. General: Propranolol should be used with caution in patients with impaire
hepatic or renal function. INDERAL is not indicated for the treatment of hypertensiv
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patient
should be told that INDERAL may interfere with the glaucoma screening test. Withdrawal ma
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart diseasr
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as rese
pine should be closely observed if INDERAL is administered. The added catecholamine
blocking action may produce an excessive reduction of resting sympathetic nervous activit
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, ororthostatu
hypotension.
Carcinogenesis. Mutagenesis, Impairment ot Fertility: Long-term studies in animals havi
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studies n
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of significan
drug-induced toxicity There were no drug related tumorigemc effects at any of the dosagi
levels. Ffeproductrve studies in anrrrrd&dtd not show any impairment of fertility that wai
| attributable to the drug
Pregnancy Pregnancy Category C INDERAL has been shown to be embryotoxic ii
sanimat studies at doses about ip, times <pre,|tgr than the maximum recommended human dose
There are no adequate and weft-conlroited studies in pregnant women INDERAL shoult
be used during pregnancy only if the potential benefit justifies the potential risk to the fetus
Nursing Iv^i&ys INDERAL is excreted in human milk. Caution should be exercised wher
INDERAL is. admtnistereddo.a nursing woman.
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and have
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia.' congestive heart failure, intensification ot AV block; hypo
tension: paresthesia of hands: thrombocytopenic purpura; arterial insufficiency, usually of the
Raynaud type 7 jw 1»UPr 'Wr w
Central Nervous System: lig^pddedness; mental depression manifested by insomnia
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; visua
disturbances; hallucinations; an acute reversible syndrome characterized by disorientation toi
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, and
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarrhea,
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with aching
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has been
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo-
tence, and Peyronie’s disease have been reported rarely. Oculomucocutaneous reactions
involving the skin, serous membranes and con|unctivae reported tor a beta blocker (practolol)
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride in a
sustained-release capsule for administration once daily If patients are switched from INDERAL
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeutic
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute tor
INDERAL. INDERAL LA has different kinetics and produces lower blood levels Retitration may
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interval.
HYPERTENSION — Dosage must be individualized. The usual initial dosage is 80 mg
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may be
increased to 120 mg once daily or higher until adequate blood-pressure control is achieved
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 640
mg may be required. The time needed for full hypertensive response to a given dosage is
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL LA
once daily, dosage should be gradually increased at three to seven day intervals until optimum
response is obtained Although individual patients may respond at any dosage level, the
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value and
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few weeks
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL LA
once daily. The usual effective dose range is 160-240 mg once daily The dosage may be
increased gradually to achieve optimum migraine prophylaxis If a satisfactory response is not
obtained within four to six weeks after reaching the maximum dose, INDERAL LA therapy
should be discontinued It may be advisable to withdraw the drug gradually over a period of
S0V0fg| WQ0kS
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group are too
limited to permit adequate directions for use.
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratories.
8833/384
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
264
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Membership
Newsletter
fHE MEDICAL SOCIETY OF NEW JERSEY
&
S
VOLUME 10
MANDATORY ASSIGNMENT— MEDICARE
HR-4170 still is pending in the U.S. Congress. It
calls for a rollback of Medicare prevailing charges to
the level set on June 30, 1983. This applies to phy-
sician services to Medicare hospital inpatients. Ad-
ditionally, physicians would be required to accept
Medicare assignment. Hospitals which do not have
agreements with their medical staffs to accept assign-
ments will be precluded from Part A-Hospital Reim-
bursement.
Regardless of the nature or extent of your Medicare
practice the passage of HR-4170 will have a tremen-
dous negative impact on you and your patients. Write
jyour senators and representatives today. Ask your
patients to write on their own behalf.
The Honorable Bill Bradley
United States Senate
Room 253
Dirksen Senate Office Building
Washington, D.C. 20510
The Honorable Frank R Lautenberg
United States Senate
Room 717
Hart Senate Office Building
Washington, D.C. 20510
The Honorable James J. Florio
House of Representatives
Rayburn House Office Building
Room 2162
Washington, D.C. 20515
The Honorable William J. Hughes
House of Representatives
Cannon House Office Building
Room 341
Washington, D.C. 20515
The Honorable James J. Howard
House of Representatives
Rayburn House Office Building
Room 2245
Washington, D.C. 20515
The Honorable Chris Smith
House of Representatives
Cannon House Office Building
Room 422
Washington, D.C. 20515
The Honorable Marge Roukema
House of Representatives
Cannon House Office Building
Room 226
Washington, D.C. 20515
The Honorable Bernard J. Dwyer
House of Representatives
Cannon House Office Building
Room 404
Washington, D.C. 20515
The Honorable Matthew J. Rinaldo
House of Representatives
Rayburn House Office Building
Room 2338
Washington, D.C. 20515
The Honorable Robert A. Roe
House of Representatives
Rayburn House Office Building
Room 2243
Washington, D.C. 20515
The Honorable Robert G. Torricelli
House of Representatives
Cannon House Office Building
Room 317
Washington, D.C. 20515
The Honorable Peter W. Rodino, Jr.
House of Representatives
Rayburn House Office Building
Room 2462
Washington, D.C. 20515
The Honorable Joseph G. Minish
House of Representatives
Rayburn House Office Building
Room 2109
Washington, D.C. 20515
VOL 81— NUMBER 4— APRIL 1984
265
The Honorable James A. Courter
House of Representatives
Cannon House Office Building
Room 325
Washington, D.C. 20515
The Honorable Edwin B. Forsythe
House of Representatives
Rayburn House Office Building
Room 2210
Washington, D.C. 20515
The Honorable Frank J. Guarini
House of Representatives
Cannon House Office Building
Room 206
Washington, D.C. 20515
SERVICE FOR CRIME VICTIMS
Compensation for losses due to injuries is available
to eligible victims of crime through the New Jersey
Violent Crime Compensation Board. In the case of the
death of the victim, payment may be ordered to or for
the benefit of the dependents of the deceased victim.
Persons who are injured while trying to prevent a
crime or while assisting a police officer in making an
arrest also may be eligible for compensation.
For more information, call 800-242-0804 or write to
Commissioner Kenneth W. Welch, Chairman, Violent
Crimes Compensation Board, 60 Park Place, Newark,
NJ 07102.
MUTUAL PROTECTION ASSOCIATION
H.R. 2095 and H.R. 2486— Physicians' and Surgeons'
Mutual Protection Associations. The AMA supported
H.R 2095 and H.R. 2486, bills that would provide tax-
exempt status to physicians’ and surgeons' mutual
protection and indemnity associations providing pro-
fessional liability coverage. The bills also provide that
initial payments made by a physician to such entities
would be tax deductible as a business expense. AMA
commented that the bills represent a reasonable step
towards providing equality of tax treatment for this
form of providing essential professional liability cov-
erage. (Letter, House Ways and Means Committee,
January 6, 1984).
PREFERRED PROVIDER ORGANIZATIONS: LEGAL
AND LEGISLATIVE ASPECTS*
It should be remembered that the Preferred Provider
Organization (PPO) is an entrepreneurial marketing
concept which seeks to achieve cost efficiencies in the
delivery of health care through the use of legal con-
tracting as a mechanism to encourage certain behav-
ior patterns. Often, these are not legislated entities and
the locus of their regulation is unclear. In addition, the
application of the law to PPOs is as yet ambiguous
since they are relatively new, and specific legislation
is limited and judicial decisions are completely lacking.
The following discussion, therefore, often deals with
potential pitfalls rather than proven traps.
The regulation of the business of insurance, includ-
‘Reprinted with pennission from the American Medical As-
sociation.
ing health insurance, is an activity reserved for the
states by Congress. All states have some sort of in-
surance code which provides for the regulation of in-
surance plans. Where legal barriers to PPO develop-
ment exist on the state level, they usually involve the
issue of whether or not it is legal in that partieulai
state to restrict the insured's free choice of provider
either by designating “preferred” providers or by creat
ing financial or other incentives to choose designated
providers. Many states have insurance code provisions
guaranteeing the beneficiary or subscriber free choice
of provider so long as the chosen provider is licensed
to perform the particular service. Several of these
states now are considering or implementing legislative
changes which seek to control health care costs by
creating competition among providers for patients and
third-party reimbursement through the selective con-
tracting mechanism.
It should be noted that self-insured employer groups
and Taft-Hartley union trusts (prime marketing
targets of many PPOs) are exempt from state insurance
regulations by virtue of pre-emptive federal law. How-
ever. that federal law was amended in January 1983
to limit this exemption from state regulation for mul-
tiple employer trusts (METs). Whether and how thel
PPO concept can be incorporated into a third-party!
health insurance package, and to what extent it will
be regulated, thus depends upon a particular state’s!
insurance laws and regulations as well as the way in
which the PPO is organized and marketed.
During the 1982 legislative session, the California
legislature enacted three laws which greatly have af-
fected the development of PPOs in that state. The first,
of these, AB 799, was enacted in response to a fiscal
crisis in the state’s Medicaid (Medi-Cal) program. This!
law authorizes Medi-Cal to negotiate selective and ex-
clusive contracts with health care providers and de->
livery systems for the provision of health care services'
to Medi-Cal recipients. The Medi-Cal negotiators also
were authorized to utilize a competitive bidding pro-
cess in lieu of negotiations where it was deemed "ex-
pedient." In the case of hospital contracts for inpatient
services, the negotiators were instructed to consider
the total funds appropriated for inpatient services. AB
799 became effective July 1, 1982, for institutional
providers, and on July 1, 1983, with respect to pro-
fessional providers. Once contracts have been signed
in an area, providers not under contract to the state
will not be reimbursed for services delivered to Medi-
Cal recipients, except for emergencies.
With the passage of AB 799, the insurance industry1
became concerned that this new infusion of competi-
tion into the Medi-Cal market would result in massive
and unreasonable increased cost shifts to the private
sector. As a consequence, AB 3480 was introduced and
passed. The intent of this legislation was to provide
that as of July 1, 1982: “An insurer may negotiate and
enter into contracts for alternative rates of payment
with institutional providers, and offer the benefit of
such alternative rates to insureds who select such
providers. Alternatively, insurers may, by agreement
with group policyholders, limit payments under a pol-
icy to services secured by insureds from institutional
providers, and after July 1, 1983, from professional
providers, charging alternative rates pursuant to con-
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
266
tract with such insurer." In other words, insurers and
hospital service plans are not only permitted to con-
tract selectively based on price with health care
providers, they also may require their subscribers to
utilize the contracting providers by limiting payment
solely to those providers (the basis for Exclusive
Provider Organizations or EPOs). Much of the impetus
for EPOs provided by AB 3480 apparently has been
blunted by a third piece of legislation, SB 2012. The
overall effect of this third bill has been to tighten some
of the provisions of AB 799 and AB 3480 by requiring
ongoing professional peer review by “professionally
recognized, unrelated third parties” of insurance com-
panies’ closed panel plans, and by prohibiting the con-
ditioning of hospital medical staff privileges on a phy-
sician’s willingness to contract with an insurer.
The overall effect of these three pieces of legislation
in the state of California has been a dramatic increase
in the level of interest and activity among hospitals,
physicians, and insurers to develop Preferred Provider
Organizations. Over 150 organizational entities have
registered names with the California Department of
Corporations. While many of these organizations may
never achieve operational status, many others were
ready to begin payment claims as of July 1, 1983, when
| the new laws took effect for professional providers. The
impetus for these PPOs is cost containment and com-
petition; to what extent they will meet these objectives
is yet to be demonstrated.
While the marketing concept of preferred provider
contracts or arrangements has arisen in several other
states, the California statutes appear to be unique in
their affirmative sanctioning of preferred provider con-
tracts and exclusive provider arrangements. Using the
California legislation as a model, however, several
states are considering legislation which would remove
the freedom of choice barrier to PPO development. In
March 1983 the Virginia General Assembly passed a
set of amendments (SB 110) to that state’s insurance
code. These amendments provide that: “One or more
insurers may offer or administer a health benefit pro-
gram under which insurer or insurers may offer
preferred provider policies or contracts . . . which limit
the numbers and types of health care services eligible
for payment as preferred providers under such policies
or contracts. Any such insurer or insurers shall estab-
lish terms and conditions which shall be met by a
hospital, physician, or other provider ... in order to
qualify for payment as a preferred provider under such
policies or contracts. These terms and conditions shall
not discriminate unreasonably against or among such
health care providers. No hospital, physician, or other
provider ... willing to meet the terms and conditions
offered to it or him shall be excluded. Neither dif-
ferences in prices among hospitals or other institu-
tional providers produced by a process of individual
negotiations with such providers or based on market
conditions, nor price differences among providers in
different geographical areas, shall be deemed un-
reasonable discrimination. Preferred provider policies
or contracts offered pursuant to this section shall
provide for payment for services rendered by non-
preferred providers, but such payments need not be
the same as for preferred providers.” Thus, the Virginia
legislation paves the way for the establishment of
Preferred Provider Organizations that utilize copay-
ment incentives, but expressly prohibits the establish-
ment of Exclusive Provider Organizations.
In 1982, the state of Arizona passed legislation to
create the Arizona Health Care Cost Containment Sys-
tem (AHCCCS). This system is an experimental
alternative to a traditional Medicaid program for Ari-
zona however, it permits Arizona to obtain federal
Medicaid dollars. The overall goal of the AHCCCS plan
is to develop and test an innovative payment and de-
livery system for providing health care services which
facilitates cost containment while, at the same time,
encouraging quality care in an efficient fashion. One
of the unusual aspects of this program is that persons
eligible to participate in the program will include not
only the indigent and the medically needy, but also
county, state, and private sector employees whose em-
ployer offers health care coverage through this system.
The AHCCCS model includes six major devices for
containing costs: the creation of a network of primary
care providers who will act as case managers in
authorizing and supervising largely acute medical care
to recipients; prepaid capitated contracts; competitive
bidding for selective contracts; the use of nominal
copayments; limited restrictions on choice of providers
and primary care physicians; and capitated payment
by HCFA to the state of Arizona.
Arizona has received a demonstration waiver from
HCFA which includes provisions for cost-sharing re-
quirements and for restrictions on free choice of
provider. One interesting element of the Arizona sys-
tem is that a statewide agency is responsible for con-
tracting with providers at the county level to provide
care for each county. The implementation of this pro-
gram is divided into three stages: implementation first
among the indigent and medically needy, second
among state and local government employees, and last-
ly availability to private sector employers as one health
insurance alternative. This program uses selective con-
tracting and a PPO-type model as a mechanism to
accomplish its cost-containment goals. Implementa-
tion of the program still is in a very early stage, so that
no conclusions can be drawn regarding its cost effec-
tiveness yet.
A 1983 Florida law authorizes and states that it shall
not be construed as an unfair method of competition
or an unfair or deceptive act or practice for commercial
and not-for-profit insurers or groups of insurers
providing individual health insurance or group,
blanket or franchise health insurance to negotiate or
enter into contracts with licensed health care
providers for alternative rates of payment. Payments
may be limited under a policy pursuant to agreement
with insureds, to such alternative rates regardless of
the provider chosen by the insured as long as the
insurer offers the benefit of such alternative rates to
insureds who select designated providers.
A 1983 Minnesota law states that it shall not be
within the prohibition against discrimination and re-
bates for a commercial or not-for-profit insurer, in the
case of a group health insurance policy, to pay differing
amounts of reimbursement to insureds who elect to
receive health care services from providers designated
by the insurer. The insurer is required annually to file
summary data regarding the financial reimbursement
VOL. 81— NUMBER 4— APRIL 1984
267
offered to providers so designated and to disclose infor-
mation regarding the name used to describe the
special arrangement, the names of all providers desig-
nated by the insurer under the arrangement, and the
terms of the agreements with designated health care
providers.
The 1983 Wisconsin budget contains a section
which becomes effective July 1, 1984, regarding PPOs.
It provides that:
• A preferred provider plan is a health insurance
contract which limits participation to providers
selected by the health insurer; an open panel plan is
a health insurance contract which does not limit par-
ticipation except to providers who have agreed to par-
ticipate in the plan and abide by its terms.
• PPOs may be established by an insurer or other
person.
• Employers offering PPOs to their employees must
also offer an open panel plan with substantially
equivalent benefits. The employee must be given the
opportunity to change plans once a year.
• No PPO may prevent any person from choosing
among providers participating in the plan, except by
requiring selection of primary providers when reason-
ably possible.
PPOs also must pay for services rendered by non-
PPO providers who are willing to participate in the
plan and abide by its terms. If such selection is made,
the non-PPO provider is to be paid an amount he
agrees to, but not more than would have been paid to
a PPO provider. The plan may not require that pay-
ment to the non-PPO provider be less than what would
be paid to a PPO provider.
• The PPO may require that a person who chooses
non-PPO providers pay an amount up to $2,500 an-
nually in addition to premiums and deductibles. (The
Commissioner may set the figure lower.) Subject to
this provision, the PPO may require a person to pay,
in addition to any applicable deductible, up to 20 per-
cent of payments to non-PPO hospitals.
• The Insurance Commissioner will issue adminis-
trative rules to ensure that patients need not travel
excessive distances to receive their care from the PPO
providers, and to ensure continuity of patient care.
Given the increasingly competitive nature of today’s
medical care marketplace, it seems reasonable to sup-
pose that other states will follow the action already
taken by states like California, Arizona, Virginia,
Florida, Minnesota, and Wisconsin in creating a more
permissive environment for selective contracting in
both the public and private sector delivery of health
care. At this writing, a bill is pending in Colorado and
a proposal is expected to be introduced in Michigan
during the next legislative session. Bills have been de-
feated in the states of Utah and Nevada.
On the federal level, a bill (HR 2956) was submitted
to the House of Representatives in May 1983 by Con-
gressman Wyden (D-Ore.) which, if passed, would
supersede all “state insurance or other law or regu-
lation” with regard to the negotiation of selective and
exclusive contracts between “group health plan pay-
ors” and “providers of health care services.” Represen-
tative Wyden’s bill therefore would legalize the con-
cepts of both a Preferred Provider Organization as well
as an Exclusive Provider Organization.
The intent of this bill is to pre-empt state laws and
regulations dealing with free choice of provider. Phy-
sicians, hospitals, and insurers interested in organiz-
ing or working with PPOs need to be wary of the pos-
sible antitrust implications of their activities, however,
since this is an unsettled area of the law.
Since 1975, the U.S. Supreme Court increasingly has
subjected the activities of the learned professions and
their associations to scrutiny under the federal anti-
trust laws. These laws are intended to protect and
foster market forces so as to insure free and open
competition between and among sellers of goods and
services. One of the difficulties inherent in applying
the principles of antitrust law to health care is in the
determination of what constitutes the necessary con-
ditions of a state of workable competition. Since there
has been so much regulation of the health care field
over time, no one is certain what the “competitive solu-
tion” would look like. Philosophically, the concepts of
antitrust and regulation are in diametric opposition
to each other as ways to deal with market imperfec-j
tions. Antitrust seeks basically to make the market
work more efficiently, whereas regulation usually seeks!
to replace market forces in determining resource al-
location.
Whenever there is collaboration or cooperation
among natural competitors or individuals engaged in
the same business, there exists a potential for anti-
trust implications. However, there are certain activities
relating to health provider contracting which are more
likely to create antitrust risk. These are: communica-
tions regarding prices, or exchanges of price or cost
information from which it could be inferred that com-
peting providers have agreed to affect prices charged
to third-party payors; communications or coordinated
conduct from which it could be inferred that compet-
ing providers have agreed not to compete as to particu-
lar service, geographic, or patient markets; agreements;
by competing providers to refuse to deal with particu-
lar third-party payors or to deal with them only on
particular terms or conditions; agreements between
one provider group (e.g. physicians) and a third-party
payor which affect the terms or conditions upon which
another provider group (e.g. chiropractors, clinical psy-
chologists, or optometrists) may be compensated; the
formation of entities (such as PPOs) for the purpose
of dealing jointly with third-party payors; control of
third-party payors by providers whose compensation
is determined by the third-party payor; and provider
peer review of utilization and fees charged by com-
petitors.
The major antitrust statutes which are applicable to
medical care delivery are: Sherman Antitrust Act: Sec-
tion 1 of the Sherman Act prohibits contracts, agree-
ments, combinations, or conspiracies in restraint of
trade. This would include price-fixing, group boycotts,
tying arrangements, division of markets, and customer
allocation. Section 2 of the Sherman Act prohibits
monopolization, conspiracies to monopolize, and cer-:
tain attempts to monopolize. Federal Trade Com-
mission Act: The Federal Trade Commission Act
prohibits unfair methods of competition and unfair or
deceptive acts or practices to consumers.
Other basic antitrust statutes are of less importance
in the health care area. The Robinson-Patman Act
268
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
lealing with price discrimination, and Section 3 of the
playton Act, which prohibits certain tying arrange-
nents and exclusive dealing agreements, apply only to
he sale of goods and commodities, not services. How-
ver, tying and exclusive dealing arrangements relat-
ng to services may be challenged as "unfair methods
)f competition" under the Federal Trade Commission
\ct. Furthermore, Section 7 of the Clayton Act
rrohibits acquisitions of corporate stock or assets that
nay result in the substantial lessening of competition
)r creation of a monopoly in any “line of commerce."
The most common charges to which PPOs may be
subjected are price-fixing and restraint of trade. As
loted earlier, agreements among competing providers
vhich have the purpose or effect of raising, depressing,
fixing, pegging, or stabilizing fees may be judged to
constitute horizontal price-fixing — a per se violation of
I Section 1 of the Sherman Antitrust Act. A per se vio-
lation consists of conduct that has been determined
to be unreasonably anticompetitive without regard to
its business justification or actual effect on com-
petitive conditions in individual cases. This rule has
been asserted by the Federal Trade Commission to
challenge the use of relative value scales (with or
without agreement on a specific conversion factor) to
determine fees. The same rule was applied by the U.S.
Supreme Court in 1982 to prohibit the Maricopa
Foundation for Medical Care’s establishment of a
maximum fee schedule. In this case, the Court rejected
arguments of the provider members of the Foundation
that their fee arrangement did not constitute per se
horizontal price-fixing because the Foundation was
analogous to a partnership or joint venture marketing
a new or unique service. Concluding that the Foun-
dation plan failed to satisfy the factual premises of
such an argument — since the Foundation lacked the
attributes of integration and risk-sharing found in the
true joint venture, and offered no services different
from those offered individually by its members— the
Court expressed no opinion as to its validity.
By contrast, the lower courts consistently have up-
held standard term reimbursement contracts (such as
the physician participation contracts used by most
Blue Cross/Blue Shield Plans), where they are entered
into separately by third-party payors and individual
providers. These courts have not considered the prac-
tice of limiting reimbursement in accordance with in-
surer-determined maximum fee schedules to con-
stitute horizontal or vertical price-fixing— at least in
the absence of evidence demonstrating provider con-
trol of the insurer’s reimbursement policies.
Groups or organizations of independently practicing
competing physicians that combine in a PPO arrange-
ment to negotiate contracts or use relative value scales
to determine fee schedules expose the PPO and its
members to a significant risk of antitrust liability. PPO
arrangements based upon reimbursement schedules
determined by groups or entities independent of
providers entail much less risk; especially if the con-
tracting entity is free of any financial or controlling
interests of hospitals, employers, or insurers partici-
pating in the plan, and negotiates bilateral contracts
with individual providers, integrated group practices,
professional partnerships, and institutions employing
salaried staff. Antitrust risks increase as the PPO plan
departs from such "brokerage" arrangements struc-
tured around an independent intermediary that de-
termines reimbursement policies and maximum fee
schedules, and negotiates contracts with payors and
providers.
Alternatives to the “brokerage" type PPO plan in-
clude partnerships of physicians, and integrated joint
ventures between hospitals or hospital groups and
members of their medical staffs. Maricopa did not fore-
close the possibility that such arrangements, if suffi-
ciently integrated as a risk-bearing enterprise or or-
ganized to provide a unique form of service not other-
wise available in the market, might escape per se con-
demnation as horizontal price-fixing combinations.
The rule of reason standards that may be applied to
such PPOs cannot be predicted with precision. In bal-
ancing the competitive benefits and detriments of
these integrated forms of practice, however, the collec-
tive market power of the participating providers will
be considered one of the decisive measures of com-
petitive impact. Authorities in antitrust law and eco-
nomics differ with respect to the combined market
share that might be indicative of a PPO’s power to
affect market prices or exclude competition. Partial
integration of providers representing as little as 10
percent of market capacity may be considered an-
ticompetitive in some cases, while a joint market share
of 35 to 40 percent may be held insufficient to estab-
lish an unreasonable restraint of trade in others.
Market share also is regarded as a crucial determi-
nant of legality under Section 2 of the Sherman Act.
A PPO representing a predominant share (roughly 70
percent) of provider services in a distinct geographic
market risks charges of monopolization. Lesser market
shares may suffice to establish a dangerous probability
of dominance required to sustain allegations of at-
tempt to monopolize. Since many medical societies
represent a significant portion of the physicians in
their local markets, it may be unwise for them to or-
ganize PPOs, or serve as the locus for PPO information.
Another form of a per se violation of antitrust laws
is the group boycott. If providers are permitted to form
partnerships or joint ventures for the purpose of deal-
ing collectively with private third-party payors, they
still may incur boycott liability premised upon agree-
ments not to deal with a particular person or entity.
The most obvious source of boycott claims against
provider-based PPOs would be other providers adverse-
ly affected by PPO determinations or poli-
cies— especially those providers initially denied access
to, or dropped from PPO participation for failure to
comply with quality or utilization criteria and policies,
and those whose market base is eroded by the market-
ing efforts of the PPO. Boycott claims also may arise
where a provider-sponsored PPO threatens or refuses
to deal with a third-party payor seeking to affect its
reimbursement policies or methods of fee determina-
tion. Such claims are more likely to be encountered,
and to create a greater risk of liability, when the PPO
represents a large share of the market, or its actions
are undertaken with the purpose or effect of influenc-
ing the level of fees. To the extent that exclusion from
the PPO denies a provider access to a resource essen-
tial to his competitive vitality, a finding of per se illegal
horizontal boycott is more likely. Fee-related refusals
VOL. 81— NUMBER 4— APRIL 1984
269
to deal raise serious risks of per se condemna-
tion—either standing alone, or in conjunction with
broader price-fixing allegations.
In many cases involving group boycott allegations,
the courts apply a “rule of reason” standard rather
than the per se rule. The rule of reason standard allows
the defendants (the PPO and its members or sponsors)
an opportunity to demonstrate that the procompetitive
benefits of an arrangement outweigh any alleged an-
ticompetitive effects. In other words, the PPO must be
able to establish that the purpose and effect of its
action was to enhance the quality of its services, thus
increasing its own efficiency and competitiveness and
that of the market as a whole.
As a final element of the discussion on PPOs and
antitrust implications, it should be noted that there
are circumstances under which immunity from anti-
trust scrutiny may be applicable. These include: State
Action Exemption: Practices mandated and actively
regulated by a state gain antitrust immunity. Exam-
ples of such practices may include those undertaken
pursuant to certificate-of-need programs and state
health planning: Noerr-Pennington Exception: This ex-
ception to applicability of the Sherman Act relates to
activities genuinely undertaken to affect government
policy, such as lobbying activities: McCarran-Ferguson
Exemptions: This doctrine provides antitrust immuni-
ty to “the business of insurance," if state regulated.
The Supreme Court, however, has stated that “the
business of insurance is not the same as the business
of insurance companies." The "business of insurance”
involves the sharing of risk and is restricted to the
relationship between the insurer and the insured.
While the exemptions from antitrust prosecution
exist and may be found to be applicable to some situ-
ations. it remains to be tested whether some PPOs will
be able to meet the criteria to qualify for such immuni-
ty-
in summary, antitrust questions and allegations
may be raised whenever there is collaboration or coop-
eration among a group of competitors. The effect of
such questioning, however, will depend upon how the
PPO is organized, who negotiates what with whom, the
size of the market share involved and whether the pro-
competitive effect of the arrangement outweighs the
anticompetitive results. Moreover, not every con-
stituted restraint of trade necessarily is prohibited,
only those that are deemed by the courts to be un-
reasonable or to constitute per se violations.
The purpose of this section is to develop a framework
for physicians to evaluate PPO contracting op-
portunities. The discussion will focus on a physician’s
perspective in responding to an organization which is
sponsoring a PPO. An analysis is provided of factors
which need to be evaluated in PPO contracting, im-
plications involved in contracting for a physician's
medical practice, and questions which should be
raised in assessing a particular PPO proposal.
Once signed and agreed to, a contract is a legally
binding document. It will be to a provider’s advantage,
therefore, to exercise a great deal of caution in evalu-
ating contracts, negotiating terms, and understanding
the legal obligations and implications created by such
a contract. The physician should read the contract
thoroughly, being careful to understand all of the
language of the terms and obligations. It is advisable ,
to obtain legal assistance in reviewing any such agree ,
ments prior to signing them. ,.(
Prudent business practice would seem to dictate s
that a physician contemplating a contract with ar
unfamiliar entity makes himself aware of the legit
imacy and fiscal soundness of the organization offer
ing the contract. Before entering into such a contrac
a physician should carefully research the contracting
entity’s financial track record and credibility. The ver
acity of information provided by the offeror of the con
tract should be checked. If, for example, physicians anc
hospitals are said to be enrolled, physicians shoulc
check to see that such contracts really do exist. Phy
sicians also should make certain that all important de
tails pertaining to the contract are committed to writ
ing. Finally, physicians should obtain copies of anc
review the provisions of third-party/subscriber con
tracts which may control or affect provider rela
tionships with PPO patients, other providers’ hospi
tals, or the third-party payor or PPO.
One important issue in provider contracting relates
to the level of risk to be assumed by each of the con
tracting parties; i.e. the potential financial loss or re-
sponsibility associated with performance under the
terms of the contract. In evaluating the provisions ol
a preferred provider contract, physicians must be
prepared to evaluate how much of this risk they are
willing to assume as well as the costs associated with
that risk.
General financial considerations which should be
evaluated by physicians before entering into a selective
provider contract include the following:
• Scope of Services: A clear definition of the scope
of services covered by the contract is necessary in order;
to evaluate the level of risk associated with the
provider’s assumption of the contract. Clearly, the
more vague the understanding with regard to scope of
services to be provided, the higher the element of risk.
• Scope of Practice: In a similar vein, it will be im-
portant for physicians to evaluate carefully any clauses
in the proffered contract which seek to define the
scope of a physician’s practice. Such clauses may in-
clude limitations on services which may be performed
under the contract but for which the physician is
otherwise qualified and licensed, limitations on which
institutions the physician may use to hospitalize his
patients, and limitations on physician referral pat-
terns. The most extreme form of limitations on scope
of practice would be illustrated by a contract which,
when signed, prohibits the signatory physician from
participating in any other contract agreements such
as HMOs, IPAs, or other PPOs.
• Unit of Payment: The two most common alterna-
tive unit of payment systems for physician reimburse-
ment are fee-for-service and capitation. Fee-for-service
payment has the advantage to the physician of being
virtually risk free. The physician is paid each time a
unit of service is delivered. The disadvantages of this
system to the payor are the lack of control and predic-
tability with regard to price and the lack of built-in
incentives for the provider to monitor utilization. Vari-
ations on the fee-for-service system include discounted
charges and limitations on increases. All of the PPOs
surveyed by the AMA pay physicians on a fee-for-ser-
270
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
/ice basis. Capitation is a method of physician reim-
Dursement based on the number of individuals en-
-olled instead of . the number of services delivered. This
s the physician reimbursement system commonly em-
ployed by Health Maintenance Organizations. The
provider who signs a capitated contract usually as-
sumes both the obligation to provide services for the
fixed premium, and the financial risk for the cost of
providing the service regardless of what is required.
Ideally, physicians should build the cost associated
with the assumption of this risk into their payment
irate. A few PPOs are beginning to experiment with this
type of payment system.
• Liability: Any clauses dealing with liability (either
the physician’s or the PPO’s) should be examined very
'carefully. If the contract requires the physician to in-
demnify the carrier against liability (known as a “hold
harmless" clause), most professional liability in-
surance policies do not provide coverage for contrac-
tually assumed liability. The physician might, there-
fore, be held personally liable for any damages against
the insurer.
I* Cost of Services: When negotiating a price for ser-
vices under a contracting mechanism, each provider
must attempt to compute the total cost of doing busi-
ness as accurately as possible. Accurate historical and
trend data will substantially enhance this portion of
the negotiation process.
BRADLEY TO SPEAK AT JEMPAC FORUM
This year’s JEMPAC Political Forum will have as its
I speaker Senator Bill Bradley. The Political Forum
will be held on Friday, May 4, 1984, at the Annual
Meeting in Atlantic City. A Wine and Cheese Reception
for the Senator will follow his address. Invitations to
JEMPAC members and those attending the Annual
(Meeting will be mailed shortly.
NJ MEMBERSHIP DRIVE
The facts are clear: in the space of little more than
a year — December 1982 to present — JEMPAC has
gained almost 200 memberships, a rate of growth un-
precedented for the New Jersey group and for AMPAC
member organizations this year generally. What is less
obvious is how that kind of accomplishment is pos-
sible— or should we ask who?
Certainly the “who” in this case represents political
action committee leadership, in the best sense of the
word. And JEMPAC has found it in Dr. Peter Amirata,
a general surgeon whose professional home is in
Belleville and whose avocation is making physicians
more responsive to the political process. Like many
other physician-leaders— he was installed as President
of the Essex County Medical Society in May of
1983 — Dr. Amirata saw his organization’s member-
ship drive as a challenge and an opportunity. Just as
importantly, he had the drive and imagination to make
the most of it.
Amirata himself sees it more modestly. “It all began
last May (1982) at the state medical society meeting
in Trenton," he explains. “Dr. Kovacs, the incoming
president, made a speech about how weak the or-
ganization was in terms of political donations and
memberships. He asked everyone to seriously consider
the importance of political action, and that started me
thinking."
Amirata’s first move was a daring one: “I was in-
stalled on May 12 as President of Essex County, and
I asked Dr. Kovacs to be guest speaker. He said that
the entire state of New Jersey had raised $14,000 in
political contributions through physicians. Then I
made my own pledge to him — that in one year, Essex
County would be able to raise at least as much money
as the entire state (JEMPAC) had.”
The drive to fulfill the pledge began when Dr.
Amirata marshalled a steering committee of phy-
sicians to help with publicity and promotion. JEMPAC
next sent out letters to 1,500 physicians, largely
through the efforts of Arthur Ellenberger, the Ex-
ecutive Secretary. (“I couldn’t have done it without
him," says Dr. Amirata). The letters were, of course,
appeals for funds, but with a difference. Amirata made
sure that an appropriate member of the committee had
handwritten a personal note at the bottom of each
(“how’s your wife?”) so that each physician contact
saw the human connection with a known entity.
The approach, notes Amirata, has been used fre-
quently in political campaigns, but is especially ap-
propriate to physicians because “nurses usually open
all incoming mail in the doctor’s office, and will toss
anything that looks like a form letter. They’ll stop when
they see a handwritten message.”
The campaign— asking for $100 from each phy-
sician-generated an amazing 350 responses (com-
pared to 10 to 15 responses from a similar effort in-
itiated the year before). Some of the 1983 total came
from telephone followups, as well as additional pub-
licity in the Medical Society newsletter. As with any
good direct mail effort, the campaign included a sec-
ond mailing a month after the first. In all, the effort
netted a healthy $ 1 7,000, as well as a surge in member-
ship (almost 175 memberships have come in since
July).
Having fulfilled his promise. Dr. Amirata sent a letter
to Dr. Kovacs. He got in return a letter of acknowledg-
ment, a position on the JEMPAC Board, and — he
says— a great deal of personal satisfaction.
Dr. Amirata continues to encourage active political
involvement from physicians, and practices what he
preaches. He’s been involved in several community and
state campaigns; one of the most significant involved
raising money for U.S. Congressman Bob Roe during
his bid for the governorship of New Jersey. At the same
time, the doctor can put political action in perspective.
“I find that it really hasn’t taken up too much of my
time," he says. A principal interest now is the Clara
Maass Professional Center in Belleville, where he is
president of the medical clinic, as well as his active
practice.
Does Amirata have any words for others who would
like to duplicate his feat? “I can’t stress enough that
it’s important for presidents of county medical so-
cieties to encourage the political involvement of doc-
tors, and there are many ways to do it. Too many
doctors are apathetic about politics, and there’s no
good reason for it. Whatever party they’re in, whatever
their political leanings, they’ve got to become more
active, to make themselves heard as a profession.
VOL. 81— NUMBER 4— APRIL 1984
271
Clearly, active involvement has been a benefit for Dr.
Ami rata— and for the Essex County Medical Society.
AM PAC sends hearty congratulations to both. ( AMPAC
Sustainer. November 1983)
HOW NOT TO REFORM CAMPAIGNS
The following is reprinted from Congressman Jim
Coulter's Washington Report:
With congressional elections just months away, re-
form of the campaign process is likely to be one of the
more prominent issues when Congress reconvenes.
Over the years, there has been a tendency to equate
linancial contributions with political corruption. Since
each election cycle generates more money than the
preceding one, it is predictable that there are biannual
cries that our legislators have become the puppets of
large contributors and special interests, and that this
money-based electoral system has reached the break-
ing point.
These charges are inaccurate, and they also may be
quite dangerous. The public’s confidence in its elected
representatives is being threatened by the popular no-
tion. reinforced by the media, that political “quid pro
quos" are the norm. Those who see an evil connection
between contributions and votes offer a proposal
which, they claim, will sanitize the political process.
Their solution: taxpayer-funded campaigns. While the
specifics have varied over the years, all public financ-
ing schemes are based on two major assumptions. The
first is that under the current campaign system,
challengers cannot compete with the superior money-
raising ability of incumbents. The second is that mem-
bers of Congress are beholden to the special interests,
like FACs, which have contributed to their candidacy.
Proponents of public financing wish to limit each
candidate's spending, and to require that campaigns
be funded, in whole or in part, by the government. They
suggest that since all candidates would be spending
aproximately the same amount, money no longer
would be a factor and candidates would be examined
on their own merits. Also, eliminating the opportunity
for donations with “strings attached," would ensure
that every legislator's actions mirror the views of the
majority of his or her constituents, rather than reflect-
ing a narrow interest with a big purse. Sound too good
to be true? Well, it is.
first of all, a system of public financing which gives
equal amounts to all candidates would have the un-
healthy side effect of favoring the status quo. This is
because the first task of any candidate is to become
known and have his or her name recognized by the
electorate. For the incumbent, this task largely is ac-
complished in the course of congressional duties
through press coverage, correspondence with constit-
uents, newsletters, and staff work. But the challenger,
who lacks this advantage and the government funds
which make it possible, must expend time and money
just to establish an identity in the minds of the voters.
Since the relative positions of incumbents and
challengers are unequal, a seemingly evenhanded
spending limit inherently is unfair, and would tend to
preserve the incumbent by disarming the challenger.
The second reason given for public financing of con-
gressional campaigns— to eliminate the influence of
special interest PACs— misses the mark as well. One
of the favorite arguments against PACs is that mem-
bers of Congress court PAC representatives at the ex-
pense of everybody else. However, this ignores what
PACs really are. Simply put, PACs are channels
through which individuals can pool their resources in
support of like-minded candidates.
PACs contributed less than 27 percent of all funds
during the 1981 to 1982 midterm election. Critics
point to this percentage as evidence of the “pernicious”
influence of PACs. But, in fact, there is nothing "per-
nicious” about this statistic when it is realized that
there are over 3,000 separate and often competing
PACs giving an average of $500 per candidate. With
many congressional campaigns costing $250,000 or
more, one $1,000 PAC check, or even ten $1,000 PAC
checks from the same industiy are not likely to
amount to an overwhelming corrupting influence on
a Congressman. Too often, it is forgotten that a can-
didate’s views are what attract contributions in the
first place, and not the other way around. In other
words, PACs donate to candidates who share their
point of view.
Significantly, studies have shown the American pub-
lic overwhelmingly opposes taxpayer-funded con-
gressional elections. Quite naturally, the major reasons
for this disapproval are that taxpayers don’t want their
money used to support candidates with whom they
disagree, and that the government has better things
to do than to build a welfare system for politicians. The
most serious problem in our electoral system is voter
apathy, not political corruption. Most people recognize ;
that taxpayer-funded elections would exacerbate this ,
apathy.
The high cost of campaigns, and the contributions
which finance them, will continue to be singled out as
targets for reform. But reformers who set out to slay
the dragon of money in politics will find little evidence
of the "pernicious” effects of it in the most expensive
campaigns of 1982: Lew Lehrman’s gubernatorial cam-
paign in New York; Mark Dayton’s race for the Senate;
and Adam Levin’s shot at a seat in the House. All three
lost. What is most significant, however, is that with
public financing, the biggest loser would have been the
taxpayer.
MEDICAL ASSISTANTS’ CONVENTION
The 21st Annual Convention of the American As- !
sociation of Medical Assistants, state of New Jersey,
Inc., will be held at the Cheriy Hill Hyatt on April 26
to 29, 1984. For further information and registration
contact Convention Chairman, Rosanne De Gennaro,
CMA at 201-671-7029 (after 7 p.m.).
Highlights of education programs: nutrition, stress I
management, how computers will benefit a physician's
office, anorexia medical law and ethics, cyrosurgeiy,
career opportunities, premenstrual syndrome, and
blue shield/medicare/medicaid update.
FINI
It vexes people when a man is different from his
neighbors and dares to be w’hat they are not and never
can be. j
272
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
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The Foundation provides a complete
diagnostic and consultation service for in-
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fields of medicine related to infertility.
The Foundation is supported by an in-
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most tests required for diagnosis and
treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
If your professional
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lompare these figures (based on a $20,000 vehicle):
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A professional service message from the
Medical Inter-Insurance Exchange of N.J.
Two Princess Road, Lawrenceville, NJ 08648
(609) 896-2404
‘ The Doctors' Company ”
VOL. 81— NUMBER 4— APRIL 1984
273
ANNUAL AWARDS DINNER
of
THE ACADEMY OF MEDICINE
OF NEW JERSEY
Wednesday, May 23, 1984
6:00 P.M.
at
THE CHANTICLER
Short Hills, New Jersey
1984 AWARD RECIPIENTS
EDWARD J. ILL AWARD
ALFRED A. ALESSI, M.D.
CITIZENS AWARD
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(R-12th District)
For further information, please contact:
6erWo f. EXECUTIVE OFFICES
The /\cacjemy of Medicine of New Jersey
§ Two Princess Road
° Lawrenceville, NJ 08648
(609) 896-1717
of New Jersey
\V1JV
Through the MAA 'ib^aW Y°^ stQre of
ic information. k journals, and
large collection b°f Sin'slant on-line
microfilm and p'0Vtdess information
access to c°uhn,'dmpUteriZed data
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good reason wny
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To Join, tate medical
Contact your counjy ^ Member-
society or ^ A, tb Dearborn Street,
ChfcaX^5 60610 °' °a" C°"eC<'
(312)751-6196.
References:
1 . Stone PH, Tun ZG, Muller JE Efficacy of nifedipine therapy for refractory angina
pectoris Am Heart J 104 :672-681, September 1982
2. Antman E, Muller J, Goldberg S, et al: Nifedipine therapy for coronary-artery
spasm: Experience in 127 patients. N Engl J Med 302:1269-1273, June 5, 1980.
BRIEF SUMMARY
PROCARDIA ■ (nifedipine) CAPSULES For Oral Use
INDICATIONS AND USAGE: I. Vasospastic Angina: PROCARDIA (nifedipine) is indicated for the
management of vasospastic angina confirmed by any of the following criteria: 1 ) classical pattern
ol angina at rest accompanied by ST segment elevation, 2) angina or coronary artery spasm pro-
voked by ergonovine, or 3) angiographically demonstrated coronary artery spasm In those patients
who have had angiography, the presence ot significant fixed obstructive disease is not incompatible
with the diagnosis of vasospastic angina, provided that the above criteria are satisfied PROCARDIA
may also be used where the clinical presentation suggests a possible vasospastic component but
where vasospasm has not been confirmed, e g , where pain has a variable threshold on exertion or
in unstable angina where electrocardiographic findings are compatible with intermittent vaso-
spasm, or when angina is refractory to nitrates and/or adequate doses ot beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated lor
the management ot chronic stable angina (effort-associated angina) without evidence of vasospasm
in patients who remain symptomatic despite adeguate doses of beta blockers and/or organic nitrates
or who cannot tolerate those agents
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controlled
trials ot up to eight weeks duration in reducing angina frequency and increasing exercise tolerance,
but confirmation ot sustained effectiveness and evaluation ot long-term safety in those patients are
incomplete
Controlled studies in small numbers ot patients suggest concomitant use of PROCARDIA and
beta blocking agents may be beneficial in patients with chronic stable angina, but available infor-
mation is not sufficient to predict with confidence the effects ot concurrent treatment, especially In
patients with compromised left ventricular function or cardiac conduction abnormalities When in-
troducing such concomitant therapy, care must be taken to monitor blood pressure closely since
severe hypotension can occur from the combined effects of the drugs (See Warnings.)
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect of
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol-
erated hypotension These responses have usually occurred during initial titration or at the time ot
subsequent upward dosage adjustment, and may be more likely in patients on concomitant beta
blockers *
Severe hypotension and/or increased fluid volume requirements have been reported in patients
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypass
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to be
due to the combination ol PROCARDIA and a beta blocker, but the possibility that it may occur with
PROCARDIA alone, with low doses ot fentanyl, in other surgical procedures, or with other narcotic
analgesics cannot be ruled out In PROCARDIA treated patients where surgery using high dose
fentanyl anesthesia is contemplated, the physician should be aware of these potential problems and,
if the patient's condition permits, sufficient time (at least 36 hours) should be allowed for
PROCARDIA to be washed out ot the body prior to surgery
Increased Angina: Occasional patients have developed well documented increased frequency, du-
ration or severity ot angina on starting PROCARDIA or at the time of dosage increases The mech-
anism of this response is not established but could result from decreased coronary perfusion
associated with decreased diastolic pressure with increased heart rate, or from increased demand
resulting from increased heart rate alone
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with-
drawal syndrome with increased angina, probably related to increased sensitivity to catechol-
amines Initiation of PROCARDIA treatment will not prevent this occurrence and might be expected
to exacerbate it by provoking retlex catecholamine release There have been occasional reports of
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation It is important
to taper beta blockers if possible, rather than stopping them abruptly before beginning
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed heart
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater risk for
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascular
resistance, careful monitoring of blood pressure during the initial administration and titration
of PROCARDIA is suggested. Close observation is especially recommended (or patients already
taking medications that.are known to lower blood pressure (See Warnings.)
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso-
dilation and not due to left ventricular dysfunction, occurs in about one in ien patients treated with
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diuretic
therapy With patients whose angina is complicated by congestive heart failure, care should be taken
to differentiate this peripheral edema from the effects of increasing left ventricular dysfunction
Drug interactions: Beta-adrenergic blocking agents: (See Indications and Warnings.) Experience
in over 1400 patients in a non-comparative clinical trial has shown that concomitant administration
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasional
literature reports suggesting that the combination may increase the likelihood of congestive heart
failure, severe hypotension or exacerbation of angina
Long-acting nitrates: PROCARDIA may be safely co-admimstered with nitrates, but there have
been no controlled studies to evaluate the antianginal effectiveness of this combination
Digitalis, Administration of PROCARDIA with digoxin increased digoxin levels in nine of twelve
normal volunteers. The average increase was 45% Another investigator found no increase in di-
goxin levels in thirteen patients with coronary artery disease In an uncontrolled study of over two
hundred patients with congestive heart failure during which digoxin blood levels were not meas-
ured, digitalis toxicity was not observed Since there have been isolated reports of patients with
elevated digoxin levels, it is recommended that digoxin levels be monitored when initiating, ad|ust-
ing, and discontinuing PROCARDIA to avoid possible over- or under-digitalization
Carcinogenesis, mutagenesis, impairment ot fertility When given to rats prior to mating, nife-
dipine caused reduced fertility at a dose approximately 30 times the maximum recommended hu-
man dose
Pregnancy: Category C Please see full prescribing information with reference to teratogenicity in
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys.
ADVERSE REACTIONS: The most common adverse events include dizziness or light-headedness,
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of pa-
tients, transient hypotension in about 5%, palpitation in about 2% and syncope in about 0.5%
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antian-
ginal medication Additionally, the following have been reported muscle cramps, nervousness,
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shaki-
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus, urticaria, fe-
ver, sweating, chills, and sexual difficulties Very rarely, introduction ot PROCARDIA therapy was
associated with an increase in anginal pain, possibly due to associated hypotension
In addition , more serious adverse events were observed , not readily distinguishable from the nat-
ural history of the disease in these patients. It remains possible, however, that some or many of
these events were drug related Myocardial infarction occurred in about 4% of patients and conges-
tive heart failure or pulmonary edema in about 2%, Ventricular arrhythmias or conduction disturb-
ances each occurred in fewer than 0.5% of patients.
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline phos-
phatase, CPK, LDH, SGOT, and SGPT have been noted, and a single incident of significantly ele-
vated transaminases and alkaline phosphatase was seen in a patient with a history ot gall bladder
disease after about eleven months of nifedipine therapy The relationship to PROCARDIA therapy is
uncertain. These laboratory abnormalities have rarely been associated with clinical symptoms
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive world
literature
HOW SUPPLIED: Each orange, soft gelatin PROCARDIA CAPSULE contains 10 mg of nifedipine
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069 2600-66), 300 (NDC 0069-
2600-72), and unit dose (10x10) (NDC 0069-2600-41 ) The capsules should be protected from
light and moisture and stored at controlled room temperature 59° to 77°F ( 15° to 25°C) in the man-,
ufacturer's original container
More detailed protessional information available on request © 1982 , Pfizer Inc
LABORATORIES DIVISION
PFIZER INC
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
274
Quotes from an unsolicited '
letter received by Pfizer from an
angina patient.
While this patient 's experience
representative of many
is representative ot many
unsolicited comments received,
not all patients will respond to
Procardia nor will they all
respond to Bkbw alffelPP*
for the varied faces of angina
"My daily routine consisted of
sitting in my chair trying to stay alive."
© 1983, Pfizer Inc.
"I have been able to do volunteer
work. , and feel needed and useful
once again."
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0.5%).
"My doctor switched me to
PROCARDIAM as soon as it became
available. The change in my condition
is remarkable.”
"I shop, cook and can plant
flowers again."
* Procardia is indicated for the management of:
1 ) Confirmed vasospastic angina.
2) Angina where the clinical presentation suggests a possible
vasospastic component.
3) Chronic stable angina without evidence of vasospasm in
patients who remain symptomatic despite adequate doses of
PROCARDIA
(NIFEDIPINE)
Capsules 10 mg
beta blockers and/or nitrates or who cannot tolerate these
agents, in chronic stable angina (effort-associated angina)
PROCARDIA has been effective in controlled trials of up to
eight weeks’ duration in reducing angina frequency and
increasing exercise tolerance, but confirmation of sustained
effectiveness and evaluation of long-term safety in these
patients are incomplete. Please seePROCARDIA brief summary on adjoining page
VOL. 81— NUMBER 4— APRIL 1984
275
PROFESSIONAL LIABILITY
Commentary*
Physicians Need
To Be Alert
Lawsuit Shield; Pharmacists Acting
Like Doctors; Physician Owes Duty of Care
in Employment Physical; Jack Anderson
Takes Lawyers to Task
The idea came up over dinner last
summer at her home in
suburban Grosse Pointe
Shores, Michigan, Yolanda Mascarin recalled. Why
couldn't someone do something about the rising
number of medical malpractice cases being filed
against area physicians? That night, Mascarin, her
husband. Telly, a doctor, their daughter Cathy, an
anesthetist, and son-in-law Paul Huth, an attorney,
discussed the problem. The conversation got Mascarin,
who also is the mother of tennis pro Susie Mascarin,
thinking and checking court files.
Recently, she went public with her plan: a new ser-
vice in Wayne, Oakland, and Macomb Counties to let
physicians know if their patients are “lawsuit-mind-
ed." The company. Physicians’ Alert Inc., was an-
nounced in a mailing to 7,600 physicians in the tri-
county area. Mascarin believes it is the first such busi-
ness of its kind in the eountiy.
The membership fee is $150 per doctor for 50 name
checks over six months. Mascarin’s staff of seven will
check court records and let participating doctors know
it their patients have initiated previous civil suits. If
the doctors want more names checked in the six-
month period, she charges an additional $2 per name.
The mailing notice said that the new service would let
doctors know that patients with a litigation history
might be “a potential high risk” and “a stressful pa-
tient to accommodate." “Then the doctor can make his
own assumptions about how to handle it,” said
Mascarin, whose husband’s practice as an obstetri-
cian-gynecologist puts him in the highest risk group
for malpractice suits.
Mascarin, who is running the service out of her
home with the aid of a computer, said she planned to
expand the service within six months to oral surgeons,
dentists, podiatrists, chiropractors, and others.
Huth, legal advisor to the new business, said doctors
using the information provided by Physicians’ Alert
would have four choices: “One is not to see the patient
two is to charge them more for the additional risk
three is to (medically) chart them more carefully: oi
four, not to do anything other than be aware.”
Huth says the new firm is simply distributing public
information it feels may be useful. “Just because
they’re litigation-minded doesn’t mean they would file
malpractice suits. There seems to be a strong correla
tion, but we’re not making that case,” Huth said.
A spokesman for the Michigan State Medical Society
said doctors using the service who refused to see cer
tain patients would not be violating their code of ethics
to provide medical care.
Mascarin said a study of eveiy malpractice case filec
in the tri-county area during a three-month period ir
1982 revealed that 35 to 40 percent of the plaintiffs1
previously had filed civil suits.
Mascarin said these cases involved auto negligence
personal injuiy, product liability, and property dam
ages. Criminal, child custody, and divorce cases were;
not checked.
“We’re looking for the nuisance suits, the things that
should not have been filed. We're looking for the person
who’s looking for easy money, the person who lives of
this kind of thing. If someone falls on someone’s ice
(and sues), that’s what we’re looking for. I think the
doctors are anxious to get this help and find out who
the nuisance patients are,” Mascarin said.
Mascarin said she did not think a doctor using her
service would refuse to see a patient just because that
person had filed a product-liability suit. “I don’t thinf
they’ll be scared off by one or two (cases). They’ll be;
interested in the ones making a habit of it. This is
public information, and all we’re doing is making the;
doctor aware of it and he can handle it anyway he
wants to,” she said.
Mascarin said she hoped her new service also would
help educate the public about how nuisance suits
drive up the cost of medical care.
“It's just gotten way out of hand in Detroit. The}
make up ridiculous reasons to sue. It’s three to four
thousand dollars to settle many^ of these (nuisana
suits), and people end up with that as spending
money,” she said.
Her husband blamed attorneys for much of the in
crease in malpractice suits: “All the advertising some [
attorneys are doing says, ‘If we don't collect, you don'
pay.' So what do people have to lose if all you have tc
do is file and know it won’t go to court and you’ll ge
something out of it.”
Mascarin said his malpractice insurance costs hirr
more than $20,000 a year.
Malpractice insurance coverage of a million dollar; ;
for other high-risk doctors like orthopedic surgeons
This item from the Department of Professional Liability Con
trol, MSNJ, was prepared by James E. George, M.D., J.D., anc
A Ronald Rouse who are, respectively, Director of the Depart
ment and Director of Special Projects.
276
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
neurosurgeons, and heart specialists can cost between
$25,000 and $33,000 a year, said one insurance ex-
ecutive.
“Maybe we should say (to patients): your office visit
is $15 plus $3 for my malpractice insurance. It might
bring it home to people,” said Mascarin. (Philadelphia
Inquirer. December 21, 1983)
THESE PHARMACISTS ARE ACTING MORE
LIKE DOCTORS
Under a state grant, pharmacists in New Jersey are
being trained to advise elderly patients on the proper
use of medications. Pharmacists are sent to senior
citizen centers and retirement communities to speak
before groups or, more often, to provide one-to-one
consultations. The program, which began in one coun-
ty, has spread to 8 of the state’s 21 counties. (Medical
Economics. December 12, 1983)
MD OWES DUTY OF CARE IN EMPLOYMENT
PHYSICAL
If a corporation engages a physician to examine a
I prospective employee, does the doctor owe a duty of
care to the patient, even though there's been no prior
relationship? Yes, says a California court of appeal.
A pilot applied to an airline for a job and was told
he would be hired if he could pass a physical. The
company sent him to a doctor who reported that he
found a microaneurysm on the fundus of the eye. On
that basis, the physician diagnosed the pilot’s eon-
' dition as prediabetic, which precluded his employ-
ment. The pilot sued the airline and the doctor.
A trial court entered a summary judgment against
the pilot, and he appealed, reports Medical Liability
Advisory Service. The appellate court was impressed
by the medical evidence, which included reports from
two other doctors who could find no aneuiysm on the
fundus, or any such predisposition to diabetes.
On the basis of other evidence, the court held that
the pilot was “a very eligible candidate” for the job. The
pilot said that as a result of the “negligent, careless,
and reckless examination by the defendant,” other air-
lines also had turned him away.
The airline and the doctor contended that neither
owed the pilot a duty of care and that he should be
required to show physical injury to be entitled to sue.
This claim, the court said, was "meritless."
Reversing the judgment of dismissal, the court ruled
that the doctor owed the pilot a duty to conduct and
report the examination “with due care and to refrain
from causing the appellant harm, whether physical or
otherwise.” The court said the defendants could have
foreseen that “negligent determination or reporting” of
the man’s physical condition “could interfere with, and
indeed destroy, his ability to pursue his flying career."
(Medical World News, December 12, 1983)
ANDERSON TAKES LAWYERS TO TASK FOR
WRONGDOING
Jack Anderson, the nationally syndicated columnist,
has established as part of his column a section enti-
tled, "Citizens’ Watch." The idea is to have citizens
report to Mr. Anderson instances of waste and wrong-
doing which will help “to make democracy work."
In his column of January 4. 1984, "Citizens' Watch"
took lawyers to task for activities which fall into the
category of wrongdoing.
“Of all the complaints that flood into my office from
my citizens’ network, probably the most frequent have
to do with lawyers.
“From Oklahoma City. Earl David Shaffer writes: ’A
housecleaning of our court system is long overdue.
American citizens are victimized by crooked lawyers
who take advantage of their legal training to escape
punishment.'
“From Seattle, Eric Peterson demands: ‘Have you
ever tried to file a grievance against an attorney? For-
get it. The grievance committee will be made up of
lawyers, who are more inclined to protect fellow lawyers
than wronged clients. So what is left for you to do? File
a malpractice suit? Forget it. The judges are also at-
torneys.’
“From San Diego, a private detective, who requests
that his name be withheld, reports: ‘California has
been hit with an epidemic of lawsuits filed by am-
bulance-chasing lawyers who solicit business and offer
to take their fees out of the judgments. The lawyers
have little to lose: just the time it takes them to prepare
the paperwork. But the victims are put through the
anguish and expense of a costly legal defense. If the
lawyers lose the gamble, they can write it off. The cost
was nominal. But the victims are out thousands of
dollars and many sleepless nights.’
“From Long Island, Joel Cohen writes: ‘There is a
new breed of vultures preying upon the American pub-
lic. They’re the attorneys who con their clients into
believing they can get something for nothing by filing
claims against doctors, hospitals, corporations, etc.
Don’t they know that the cost of defending and settling
these lawsuits is passed on to the public? High-
premium malpractice insurance has become part of
every doctor's basic overhead. No wonder doctor bills
are so high. Just about everyone doing business must
retain a stable of lawyers. No wonder prices keep soar-
ing. Litigation is one of the principal causes of infla-
tion in this country.’
"From a suburb of Atlanta J.M. Hall contends: ‘Law-
yers and judges will never clean up their own pro-
fession. You simply can’t count on lawyers to discipline
themselves. It will take legislation, a legal code of con-
duct, to bring lawyering under control in America.”’
(The Trentonian, January 4, 1984)
Editorial Comment: We wait with interest to read
what Mr. Anderson’s readers have to say about phy-
sicians.
VOL. 81— NUMBER 4— APRIL 1984
277
, v- 'jt*
F,‘ • W - ^
Treatment with Navane can produce improvement in
psychotic symptoms such as hallucinatory behavior an<
unusual thought content as well as hostility, disorientati
and depressive mood,1 2 leaving the elderly patient mor
alert2 and better able to participate in the activities of
Well tolerated ^
Navane is generally well tolerated by elderly patients. 'JM
Excessive sedation or drowsiness has been reported, but
is uncommon.1 Anticholinergic effects3 and hypotension4 5
are reported, but rarely. Should they occur, extrapyramidal
symptoms can usually be readily controlled.
5 mg, 10 mg. 20 mg
Intramuscular 2 mg/ml, 5 ftigfmi
Capsules 1 mg, 2
Concentrate 5 mg
'abrief sartimary of
prescribing information
<e.::i982, Pteer ln‘c
Navane
(thiothixene) (thiothixene HCI)
References: 1. Ulil TM, Unverdi C. Wohlrade J, et al: Drug therapy of psychosis associated with
organic brain syndrome. Presented as a Scientific Exhibit at the American Public Health Associa-
tion Centennial, Atlantic City, New Jersey. November 12-16. 1972. 2. Katz MM, Util TM: Video
methodology for research in psychopathology and psychopharmacology. Arch Gen Psychiatry
31:204-210, 1974. 3. Ketai R: Psychotropic drugs in the management of, psychiatric emergencies.
Postgraduate Medicine 58:87-93, 1975. 4. Birkett DR Hirschfield W, Simpson GM: Thiothixene in
the treatment of diseases of the senium. Curr Ther Res 14:775-779, 1972. 5. Data on file at Roerig.
BRIEF SUMMARY OF PRESCRIBING INFORMATION
Navane® (thiothixene) Capsules: 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
(thiothixene hydrochloride) Concentrate: 5 mg/ml, Intramuscular: 2 mg/ml, 5 mg/ml
Contraindications: Navane (thiothixene) is contraindicated in patients with circulatory collapse,
comatose states, central nervous system depression due to any cause, and blood dyscrasias.
Navane is contraindicated in individuals who have shown hypersensitivity to the drug. It is not
known whether there is a cross-sensitivity between the thioxanthenes and the phenothiazine
derivatives, but the possibility should be considered.
Warnings: Usage in Pregnancy- Safe use of Navane during pregnancy has not been established.
Therefore, this drug should be given to pregnant patients only when, in the judgment of the
physician, the expected benefits from the treatment exceed the possible risks to mother and fetus.
Animal reproduction studies and clinical experience to date have not demonstrated any
teratogenic effects.
In the animal reproduction studies with Navane, there was some decrease in conception rate
and litter size, and an increase in resorption rate in rats and rabbits, changes which have been
similarly reported with other psychotropic agents. After repeated oral administration of Navane to
rats (5 to 15 mg/kg/day), rabbits (3 to 50 mg/kg/day), and monkeys (1 to 3mg/kg/day) before and
during gestation, no teratogenic effects were seen. (See Precautions.)
Usage in Children- The use of Navane in children under 12 years of age is not recommended
because safety and efficacy in the pediatric age group have not been established.
As is true with many CNS drugs, Navane may impair the mental and/or physical abilities required
for the performance of potentially hazardous tasks such as driving a car or operating machinery,
especially during the first few days of therapy. Therefore, the patient should be cautioned accord-
ingly.
As in the case of other CNS-acting drugs, patients receiving Navane should be cautioned about
the possible additive effects (which may include hypotension) with CNS depressants and with
alcohol.
Precautions: An antiemetic effect was observed in animal studies with Navane, since this effect
may also occur in man, it is possible that Navane may mask signs of overdosage of toxic drugs and
may obscure conditions such as intestinal obstruction and brain tumor.
In consideration of the known capability of Navane and certain other psychotropic drugs to
precipitate convulsions, extreme caution should be used in patients with a history of convulsive
disorders or those in a state of alcohol withdrawal since it may lower the convulsive threshold.
Although Navane potentiates the actions of the barbiturates, the dosage of the anticonvulsant
therapy should not be reduced when Navane is administered concurrently.
Caution as well as careful adjustment of the dosage is indicated when Navane is used in
conjunction with other CNS depressants other than anticonvulsant drugs.
Though exhibiting rather weak anticholinergic properties, Navane should be used with caution
in patients who are known or suspected to have glaucoma, or who migtit be exposed to extreme
heat, or who are receiving atropine or related drugs.
Use with caution in patients with cardiovascular disease.
Also. careful observation should be made for pigmentary retinopathy, and lenticular pigmenta-
tion (fine lenticular pigmentation has been noted in a small number of patients treated with Navane
for prolonged periods). Blood dyscrasias (agranulocytosis, pancytopenia, thrombocytopenic
purpura), and liver damage (jaundice, biliary stasis) have been reported with related drugs
Undue exposure to sunlight should be avoided Photosensitive reactions have been reported in
patients on Navane.
Neuroleptic drugs elevate prolactin levels: the elevation persists during chronic administration.
Tissue culture experiments indicate that approximately one-third of human breast cancers are
prolactin dependent in vitro, a factor of potential importance' if the prescription of these drugs is
contemplated in a patient with a previously detected breast cancer. Although disturbances such
as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported, the clinical
significance of elevated serum prolactin levels is unknown for most patients. An Increase in
mammary neoplasms has been found in rodents after chronic administration of neuroleptic drugs.
Neither clinical studies nor epidemiologic studies conducted to date, however, have shown an
association between chronic administration of these drugs and mammary tumorigenesis; the
available evidence is considered too limited to be conclusive at this time.
Intramuscular Administration- As with all intramuscular preparations, Navane Intramuscular
should be injected well within the body of a relatively large muscle. The preferred sites are the
upper outer quadrant of the buttock (i.e. gluteus maximus) and the mid-lateral thigh
The deltoid area should be used only if well developed, such as in certain adults and older
children, and then only with caution to avoid radial nerve injury. Intramuscular injections should not
be made into the lower and mid-thirds of the upper arm. As with all intramuscular injections,
aspiration is necessary to help avoid inadvertent injection into a blood vessel.
Adverse Reactions: Note: Not all of the following adverse reactions have been reported with
Navane (thiothixene). However, since Navane has certain chemical and pharmacologic similarities
to the phenolhiazines, all of the known side effects and toxicity associated with phenothiazine
therapy should be borne in mind when Navane is used.
Cardiovascular effects: Tachycardia, hypotension, hghtheadedness, and syncope. In the event
hypotension occurs, epinephrine should not be used as a pressor agent since a paradoxical
further lowering of blood pressure may result. Nonspecific EKG changes have been observed in
some patients receiving Navane. These changes are usually reversible and frequently disappear
on continued Navane therapy. The incidence of these changes is lower than that observed with
some phenothiazines. The clinical significance of these changes is not known.
CNS effects: Drowsiness, usually mild, may occur although it usually subsides wtih continuation
of Navane therapy. The incidence of sedation appears similar to lhat of the piperazine group of
phenothiazines. but less than that of certain aliphatic phenothiazines. Restlessness, agitation and
insomnia have been noted with Navane (thiothixene). Seizures and paradoxical exacerbation of
psychotic symptoms have occurred with Navane infrequently.
Hyperreflexia has been reported in infants delivered from mothers having received structurally
related drugs.
In addition, phenothiazine derivatives have been associated with cerebral edema and cere-
brospinal fluid abnormalities.
Extrapyramidal symptoms such as pseudo-parkinsonism, akathisia, and dystonia have been
reported. Management of these extrapyramidal symptoms depends upon the type and severity.
Rapid relief of acute symptoms may require the use of an injectable antiparkinson agent. More
slowly emerging symptoms may be managed by reducing the dosage of Navane and/or adminis-
tering an oral antiparkinson agent.
Persistent Tardive Dyskinesia: As with all antipsychotic agents tardive dyskinesia may appear in
some patients on long term therapy or may occur after drug therapy has been discontinued. The
risk seems to be greater in elderly patients on high-dose therapy, especially females. The symp-
toms are persistent and in some patients appear to be irreversible. The syndrome is characterized
by rhythmical involuntary movements of the tongue, face, mouth or jaw (e.g ., protrusion of tongue,
puffing of cheeks, puckering of mouth, chewing movements). Sometimes these may be accom-
panied by involuntary movements of extremities.
Capsules
available in
5 strengths
1 mg
2 mg
-ml
5 mg
-mi
10 mg
NttMft , KUWG i
'dnfe v<
20 mg
vJftjlE ROERIG k
^■1 5”#
Concentrate
5 mg/ml
NDC 0049-5750-5'
* Navane
j Wothixene HO
CONCENTRATE
5 nig /ml *
! 30ml
AUTION; F,
•V*r<U ng«
ROeRTCH®*
Intramuscular
2 mg/ml
5 mg/ml
There is no known effective treatment for tardive dyskinesia; antiparkinsonism agents usually
not alleviate the symptoms of this syndrome. It is suggested that all antipsychotic agents
discontinued if these symptoms appear.
Should it be necessary to reinstltute treatment, or increase the dosage of the agent, or switch tc
different antipsychotic agent, the syndrome may be masked.
It has been reported that fine vermicular movements of the tongue may be an early sign of tlj
syndrome and if the medication is stopped at that time, the syndrome may not develop.
Hepatic effects: Elevations of serum transaminase and alkaline phosphatase, usually transiei
have been infrequently observed in some patients. No clinically confirmed cases of jaundic
attributable to Navane (thiothixene) have been reported
Hematologic effects: As is true with certain other psychotropic drugs, leukopenia ar
leukocytosis, which are usually transient, can occur occasionally with Navane. Other antipsychol
drugs have been associated with agranulocytosis, eosinophilia, hemolytic anemia, thror
bocytopenia and pancytopenia
Allergic reactions: Rash, pruritus, urticaria, photosensitivity and rare cases of anaphylaxis ha>
been reported with Navane Undue exposure to sunlight should be avoided. Although not expe
enced with Navane, exfoliative dermatitis and contact dermatitis (in nucsing personnel) have bet
reported with certain phenothiazines.
Endocrine disorders: Lactation, moderate breast enlargement and amenorrhea have occurre
in a small percentage of females receiving Navane. If persistent, this may necessitate a reductic
in dosage or the discontinuation of therapy. Phenothiazines have been associated with fal:
positive pregnancy tests, gynecomastia, hypoglycemia, hyperglycemia, and glycosuria.
Autonomic effects: Dry mouth, blurred vision, nasal congestion, constipation, increased swea
ing, increased salivation, and impotence have occurred infrequently with Navane therap]
Phenothiazines have been associated with miosis, mydriasis, and adynamic ileus.
Other adverse reactions: Hyperpyrexia, anorexia, nausea, vomiting, diarrhea, increase in appi
tite and weight, weakness or fatigue, polydipsia and peripheral edema
Although not reported with Navane, evidence indicates there is a relationship betwee
phenothiazine therapy and the occurrence of a systemic lupus erythematosus-like syndrome. |
NOTE: Sudden deaths have occasionally been reported in patients who have received certa
phenothiazine derivatives. In some cases the cause of death was apparently cardiac arrest (I
asphyxia due to failure of the cough reflex. In others, the cause could not be determined nor cour
it be established that death was due to phenothiazine administration.
Dosage and Administration: Dosage of Navane should be individually adjusted depending on th
chronicity and severity of the condition. In general, small doses should be used initially ani
gradually increased to the optimal effective level, based on patient response.
Some patients have been successfully maintained on once-a-day Navane therapy.
Usage in children under 1 2 years of age is not recommended because safe conditions for its usi
have not been established.
Navane Intramuscular Solution: Navane For Injection— Where more rapid control and treatmei
of acute behavior is desirable, the intramuscular form of Navane may be indicated. It is also
benefit where the very nature of the patient's symptomatology, whether acute or chronic, rendei
oral administration impractical or even impossible.
Ror treatment of acute symptomatology or in patients unable or unwilling to take oral medicatioi
the usual dose is 4 mg of Navane Intramuscular administered 2 to 4 times daily. Dosage may b
increased or decreased depending on response. Most patients are controlled on a total dai;
dosage of 16 to 20 mg The maximum recommended dosage is 30 mg/day An oral form shoul
supplant the injectable form as soon as possible. It may be necessary to adjust the dosage whe
changing from the intramuscular to oral dosage forms. Dosage recommendations for Navan;!
(thiothixene) Capsules and Concentrate appear in the following paragraphs
Navane Capsules: Navane Concentrate— In milder conditions, an initial dose of 2 mg three time
daily If indicated, a subsequent increase to 15 mg/day total daily dose is often effective
In more severe conditions, an Initial dose of 5 mg twice daily.
The usual optimal dose is 20 to 30 mg daily. If indicated, an increase to 60 mg/day total daili
dose is often effective. Exceeding a total daily dose of 60 mg rarely increases the benefici?]
response. L
Overdosage: Manifestations include musculartwitching. drowsiness, and dizziness Symptomsc
gross overdosage may include CNS depression, rigidity, weakness, torticollis, tremor, salivatior
dysphagia, hypotension, disturbances of gait, or coma
Treatment: Essentially is symptomatic and supportive. For Navane oral, early gastric lavage i
helpful For Navane oral and Intramuscular, keep patient under careful observation and maintai
an open airway, since involvement of the extrapyramidal system may produce dysphagia ani
respiratory difficulty in severe overdosage. If hypotension occurs, the„standard measures fc
managing circulatory shock should be used (I.V. fluids and/or vasoconstrictors.)
If a vasoconstrictor is needed, levarterenol and phenylephrine are the most suitable drugs1
Other pressor agenjs, including epinephrine, are not recommended, since phenothiazine deriva:
tives may reverse the usual pressor action of these agents and cause further lowering of the bloc
pressure.
If CNS depression is present and specific therapy is indicated, recommended stimulant,
include amphetamine, dextroamphetamine, or caffeine and sodium benzoate Stimulants the,
may cause convulsions (e g. picrotoxin or pentylenetetrazol) should be avoided Extrapyramidc
symptoms may be treated with antiparkinson drugs
There are no data on the use of peritoneal or hemodialysis, but they are known to be of little valuii
in phenothiazine intoxication.
ROeRIG<®
A division of Pfizer Pharmaceutical! ,
280
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Editorial
Preventing Death
from “Hits”
A. Arthur Sugerman, m.d.
The report on deaths related to the use
of heroin, methadone, and “hits” in New
Jersey in 1980 and 1981 is reported.
The ingredients of “hits” come from
prescriptions, and the author urges
control in prescribing these drugs.
On page 291, Feuer and French report on deaths
related to the use of heroin, methadone, and "hits" in
New Jersey during 1 980 and 1981. Overdoses of heroin
account for 126 deaths, methadone for 46, and "hits"
for 36, while another 19 were due to mixtures, of which
9 were of “hits" and other drugs. The average age of
the 31 males and 5 females who died of “hits” overdose
was 22.
This dangerous poison which almost always is taken
orally is a combination of two medications only too
easily obtained by prescription: codeine, usually com-
bined in 1 grain dose with 5 grains of aspirin or
acetaminophen (Empirin" with codeine, Empracet"
with codeine, A.P.C. with codeine, and many other
proprietary and generic preparations), and Doriden"
(glutethimide), a widely used but also widely abused
hypnotic which can produce physical and psychologi-
cal dependence.
Although codeine is an opiate, it is a very safe
narcotic when used in therapeutic amounts and very
rarely is used as the drug of first choice by addicts.
However, when heroin and other preferred opiates be-
come temporarily unavailable, codeine is used as a
readily available substitute. Doriden" may be lethal in
doses as low as 5 gm but the usual acute lethal dose
is 10 gm to 20 gm. The chronically dependent user of
Doriden" is in great danger if its use is discontinued
abruptly, as withdrawal symptoms may include grand
mal seizures.
In California, the combination of Doriden" and co-
deine #4 is known as "loads" or “dors and fours” and
Cohen states that the use of this combination in
southern California was responsible for two-thirds of
the nation's codeine-related deaths during 1981.1
Cohen suggests that the switch to such oral combina-
tions is due to the poor quality of currently available
street heroin. However, Feuer and French provide
evidence that the users of “hits" are very seldom heroin
users, and are unlikely to show evidence of any in-
travenous use of drugs. They are younger, less ex-
perienced, and probably nonaddieted; they take “hits”
orally as a convenient way of obtaining a high like that
of heroin.
As physicians, we can do little to control the use of
street heroin, but the ingredients of “hits” come entire-
ly from physicians’ prescriptions. Deaths from “hits”
were reduced sharply in California by prosecuting pri-
vate physicians and “stress clinics" who were prescrib-
ing large amounts of these drugs. If we must prescribe
hypnotics, there are several benzodiazepines which are
much safer than Doriden". We should prescribe
analgesics in necessaiy quantities only, and avoid co-
deine if aspirin or acetaminophen alone is enough.
This is a simple way to save 30 to 40 or more lives a
year in New Jersey.
REFERENCE
1. Cohen S: Codeine use and abuse. Drug Abuse and Al-
coholism Newsletter XI
VOL. 81— NUMBER 4— APRIL 1984
281
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282
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Hospital Governing
boards*
Medical Staff
Participation on the
Hospital Governing
Board
Vincent A. Maressa, j.d.
To assist these governing board
members in evaluating the quality of
care, the board should be composed of
three to five attending medical staff
members and programs should be
presented to the governing board
acquainting them with medical and
patient care issues.
Hospital governing boards are re-
sponsible for the quality of care
rendered in their institutions.
When the quality of care provided by physicians is
reviewed, that review is conducted almost exclusively
by the medical staff subject to final action of the gov-
erning board.
New Jersey presents an additional component of re-
view in that PSROs conduct physician reviews on pa-
tients insured by both federal and nonfederal pro-
grams because of the DRG program.
Not infrequently, the decision rendered by a hospital
review committee conflicts with a review conducted by
a PSRO on the care rendered to the same patient. Since
Medicaid will not recognize internal review, but re-
quires the use of external review organizations, the
potential for differing decisions is magnified.
The hospital governing board, therefore, may find
itself in a position of having to evaluate several reports
from different sources on the same issue.
Governing board members must balance consistent-
ly their loyalty to the hospital, its patients, and the
community served by the hospital. Sometimes persons
appointed to hospital governing boards are not fa-
miliar with the operation and administration of hospi-
tals, the practice of medicine, and the provision of
other types of health care services. They rarely talk, if
ever, to physicians on the medical staff. Consequently,
they may have no appreciation of all the complex and
far-reaching issues they are deciding.
There are two steps we suggest to meet the issue of
assisting a governing board in evaluating the quality
of care rendered in their hospital.
The medical staff of each hospital is an extremely
valuable asset that has been underutilized. Every hos-
pital governing board should have three to five mem-
bers of the attending medical staff, elected by the medi-
cal staff, to serve as members of the governing board.
Programs should be presented by the medical staff
to the governing board to acquaint them with medical
and patient care issues. These could be structured to
take no more than one hour and could be presented
on a bi-meeting basis.
The perspective of the medical staff is vital to the
function of the hospital.
Economic pressures on hospitals are increasing. It
is currently stated that 40 New Jersey hospitals had
negative operating results in 1982. While bottom-line
orientation has desirable effects it also has the poten-
tial of adversely impacting the quality of care. Trustees
can assure themselves of circumstantial guarantees of
adequate judgment on quality issues by providing for
significant input from and discussions with their
medical staff.
*The material for this column is eoedited by Arthur Krosnick.
M.D., Editor, The Journal. MSNJ; Vincent A. Maressa, M.D.,
Executive Director, MSNJ; and James E. George, M.D., J.D.,
Director of Professional Liability, MSNJ.
VOL. 81— NUMBER 4— APRIL 1984
283
© 1983 Health Wav:
Henry Mineur, M.D., Cardiologist, Crai
Speaker of the House of Delegates of the Medical Society of Ni
"Sadly, as the cost of medical
care increases and the scope of
many health insurance pro-
grams decreases, my patients
wind up in a terrible squeeze.
I found a very satisfactory solu-
tion. I became a participating
physician in Health Ways.
With HealthWays, I can prac-
tice the kind of medicine that
will truly benefit my patients
without worrying about their
financial positions because of
the HealthWays unique physi-
cian reimbursement policy.
That's a significant plus.
In addition, the administra-
tive and financial structure of
HealthWays is fighting the as-
tonishing escalation of costs by
covering procedures easily done
on an out-patient basis rather
than in the hospital. That makes
a lot of sense. So does their
policy of covering routine
check-ups. And since the bills
THE JOURNAL OF
go directly to HealthWays, the
specter of unpaid bills is elimi-
nated."
HealthWays can be most valu-
able to your practice too. For
more information, call Jon Mar-
sicano, M.D., Vice President,
Medical Affairs, at 201-636-6200
or 609-394-1995.
HealtliWays
THE WAY TO BETTER \ HEALTH CARE.
MEDICAL SOCIETY OF NEW JERSEY
284
Physician
Legal
Bulletin
'HE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 3
Professional Liability and
the Anesthesiologist
James E. George, m.d., j.d., and Madelyn S. Quattrone, j.d.*
Of all medical specialties,
anesthesiology perhaps has
the highest potential for
severe adverse conseqences to the patient. When some-
thing goes wrong during the administration of
^anesthesia, the consequences may be death, coma, or
vegetative states. These consequences are tragic for the
patients and families involved. The severity and per-
manency of some anesthesia occurrences are an im-
portant reason why patients' families are most unwill-
ing to accept a mysterious explanation for why their
i loved one did not come out of anesthesia satisfactorily
While not every anesthesia occurrence can be equated
with negligence, the tragic consequences of anesthesia
mishaps often result in a lawsuit.
This issue of the Physician Legal Bulletin focuses
on the problems of professional liability for anesthesia
mishaps from three perspectives. First, the public’s
perception of anesthesia and its inherent risks are
examined in the context of recent media treatment of
the subject. The physician who is aware of his patient’s
perception of anesthesia may be better equipped to
deal with patient concerns regarding the risks of
I anesthesia Secondly, the article presents several brief
synopses of recent medical malpractice cases which
resulted in large juiy verdicts or out-of-court settle-
ments. The cases were selected from many reported in
the American Trial Lawyers Reporter to illustrate the
magnitude of potential damage awards in cases result-
ing in death or serious injury to the patient. The article
concludes with some risk reduction suggestions and
a brief analysis of anesthesia claims data gathered by
the Risk Prevention Department of the Medical Inter-
Insurance Exchange of New Jersey.
THE PATIENT’S PERCEPTION
In current years, the public has become more in-
formed about the risks of anesthesia. Unfortunately,
the lay public not always is able to distinguish between
the unpreventable occurrence and that caused by fail-
ure to exercise due care.
A recent example of media treatment on the subject
is “Deep Sleep,” from ABC-TV newsmagazine, 20/20,
which aired April 22, 1982. Viewers were told, “This
year ( 1 982) 6,000 patients will die or suffer brain dam-
age” as a result of “human error, carelessness, and a
critical shortage of anesthesiologists." The following is
a brief account of the show, taken from a transcript
provided by ABC.
Dr. Eli Brown, chairman of the department of
anesthesia at Sinai Hospital, Detroit, was shown dem-
onstrating the induction of anesthesia in a routine
gallbladder operation. Reporter Tom Jarriel observed,
‘From the Department of Professional Liability Control,
MSNJ, where Dr. George is Director and Editor of PLB and
Ms. Quattrone is Assistant Editor of PLB. Correspondence
may be addressed to A. Ronald Rouse, MSNJ, Two Princess
Road, Lawreneeville, NJ 08648.
VOL. 81— NUMBER 4— APRIL 1984
285
There is little margin for error; with general
anesthesia it takes less than five minutes before a
mistake can result in irreversible brain damage. When
the anesthesia is administered properly the outcome
is predictable.”
A physician-attorney. Dr. Walt Ward, was interviewed
next and remarked, “They’re . . . putting people down
near death, and then bringing them back. And that’s
the problem sometimes, bringing them back."
Jarriel then cited what 20/20 considered “three sig-
nificant problems that make anesthesia unnecessarily
dangerous. Problem number one is human error . . . the
primary cause of anesthesia accidents." This opinion
was affirmed by Dr. Ward who said, from his own ex-
perience, that “probably 80 to 90 percent of these ter-
rible accidents could have been avoided with proper
attention."
Next, Dr. Susan Dorsch, an anesthesiologist, was
shown demonstrating the way an oxygen analyzer
works. “This will alarm you, this will alert you, by this
very irritating noise, that something is wrong and cor-
rective action needs to be taken immediately," she said.
Jarriel observed, “These safety devices are not man-
datory. Although an oxygen analyzer costs less than
$700, one out of four hospitals does not have this
backup safety device." Jarriel then interviewed the wife
of a patient who experienced severe injury when at the
end of surgery the oxygen was turned off instead of
nitrous oxide. He noted that the hospital did not have
an oxygen analyzer.
Jarriel defined problem number two as “a manpower
shortage." He noted, “Places like Mobile, Alabama, do
not attract anesthesiologists." Mobile’s solution, he
said, is the use of highly trained nurses. Nurses are
not doctors, he said, “and in times of crisis, that dif-
ference has had tragic results."
A New York nurse anesthetist, who asked 20/20 to
conceal her identity, told viewers how patients some-
times are left alone under anesthesia. “There is a hos-
pital in New York City, where there are two anesthesia
people covering five operating rooms." Jarriel asked,
"And how do they do that?” The nurse replied, “Well,
they run quickly and pray a lot."
Jarriel noted that the shortage of anesthesiologists
“is expected to last until 1990.” (Notably, on January
13, 1984, results of a survey undertaken by the Ameri-
can Society of Anesthesiologists (ASA) with assistance
from the American Hospital Association were reported
in the American Medical News. The survey revealed
that only 9 percent of all operations are performed in
the 37 percent of the responding hospitals which do
not have the services of an anesthesiologist. Most of
those hospitals are located in rural areas with a mean
number of 81 beds.)
The 20/20 program then focused on what was iden-
tified as “problem number three, an uninformed pa-
tient.” Dr. Louis Blaneato, then president of the Ameri-
can Society of Anesthesiologists, was interviewed and
said: "The patient should know who his anesthesi-
ologist is, what he can do, and be able to discuss things
with him."
Jarriel then interviewed the parents of a boy who,
at the age of 8, underwent surgery to correct a “bedwet-
ting problem." The boy suffered a cardiac arrest as a
result of an anesthesia incident. The child, now 12,
requires round-the-clock nursing care to keep him
from "curling into a tight ball with muscle contrac-
tions." Volunteers were shown massaging the boy whc
could barely respond to stimuli. The parents told the
viewing audience that no one explained the risks oil
anesthesia to them, nor did they ever meet the
anesthesiologist. The parents said, "When these doc
tors made that mistake with our son, it was like taking
a gun and killing him because they just about did kil1
him. In fact, they did kill him and they brought him,
back to life, and they gave him back to us without an)
feeling or anything. If my son was hit by a car out in
the street, it would be a tragic situation. But to pulij
your son in the hands of people you trust and havf
something like this happen, it’s not the same.”
Jarriel cautioned the viewing audience to “try tc
avoid unnecessary surgery. Try to avoid general!
anesthesia— a far less dangerous local, where the pa-
tient stays awake, is usually an option. Personally meet
your anesthesiologist well before the operation, anc1
ask a lot of questions. Even that will reduce the risk.’
LITIGATION
The issue of litigation arising out of anesthesia mis-!
haps was not dealt with directly on 20/20. A brief re !
view of recent cases cited in the American Trial Law
yers Association Law Reporter reveals a plethora ol
large settlements and jury verdicts in favor of the plain-1
tiff in anesthesia cases. Common to many of these
cases were allegations of improper intubation, inade-
quate monitoring, failure to timely diagnose anoxiai
and administration of excessive amounts oi
anesthesia. A brief review of a few of these cases fol-
lows.
The case of Lake v St. Luke's Hospital, St. Louis City
Circuit Court, No 792-3656, cited at 25 ATLA L. Rep.j
278, involved a 34-year-old auto mechanic who wasj
admitted to the hospital for a tooth extraction to be|
done under general anesthesia. The plaintiff alleged;
that in preparation for the administration ol
anesthesia, the defendant anesthesiologist placed the,
endotracheal tube into the plaintiff s esophagus in-
stead of his trachea. It further was alleged that the
error was not discovered for ten minutes, during which
time the plaintiff suffered anoxia, resulting in cardiac!
arrest. It was determined that the plaintiff sustained
anoxic encephalopathy which resulted in permanent
neurological deficit.
In their defense, the hospital and anesthesiologist
contended that the plaintiffs injuiy resulted from sud-
den, unforeseeable cardiac arrest. The case was settled;
for $2 million prior to trial in favor of the plaintiff who
is confined to a nursing home.
A Mobile, Alabama, jury recently awarded $5 million
for the wrongful death of 39-year-old laborer whose
malignant hyperthermia during surgery allegedly went
undiagnosed. In that case, Hodge v Lane, Bryant,
Eubanks, et al.. Mobile County Circuit Court No.
CV-79-001289, reported at 26 ATLA Rep. 328, the pa-
tient was admitted to the hospital for removal of aj
foreign body from his eye. General anesthesia allegedly :
was administered by a nurse-anesthetist who was em-
ployed by the defendant anesthesia group. According
to the ATLA report, the patient exhibited tachycardia
and temperature elevation during surgery but the
286
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
nurse-anesthetist, who did not employ an electronic
temperature monitoring device, failed to note the pa-
tient's deteriorating condition. The nurse did not call
the attending anesthesiologist, who was working at
another hospital, until the patient suffered cardiac ar-
rest. It also was alleged that the anesthesiologist who
was on first call also was unavailable. The patient sus-
tained severe brain damage and died nine months
later.
Unfamiliarity with
monitoring equipment was
cited as a contributing
factor in a signficant
number of anesthesia
mishaps .
A recent New York case, Chin v St. Vincent Hospital,
N.Y. County Supreme Court, No. 11620/80, 25 ATLA
Rep. 278, resulted in a settlement of $1,351,000 in
favor of a 32-year-old stewardess who suffered respir-
atory arrest following an alleged administration of ex-
cessive amounts of anesthesia.
The patient, who weighed about 100 pounds, was
admitted to the hospital after fracturing her arm in a
skating accident. Prior to surgery, she received
Atropine*, Demerol*, and Valium*, IM. While in the
operating room she also received 25 mg Demerol* IV
and a regional anesthetic. The patient suffered respir-
atory arrest and was not resuscitated for five to nine
minutes, during which time she became comatose. The
patient suffers from severe spasticity of the upper
limbs and deficits in speech, sight, and movement.
A Maryland jury returned a verdict for $6 million in
favor of a 38-year-old woman who suffered a cardiac
arrest during surgery for removal of an ovarian cyst.
Subsequently, the hospital and anesthesiologist were
I sued. The plaintiff alleged inadequate ventilation, im-
proper volume reduction of an audible cardiac monitor
and alarm, and failure to respond to the patient’s need
for postoperative hydration. The case is Margolis u
Kim, et al„ D.C. Superior Court, No. CA 16740-80, 26
ATLA L. Rep. 132.
The case of Magnuson v U.S., U.S. District Court, D.
Minn., No. 3-82-26, 26 ATLA Rep 134, resulted in settle-
ment of $278,062 for the wrongful death of a 53-year-
old cancer victim who became hypotensive under
anesthesia The patient, who had squamous cell
carcinoma was admitted to a VA hospital for a
laryngectomy. During the induction of halothane
anesthesia the patient allegedly became hypotensive.
Allegations in the lawsuit included delayed resusci-
tation, excessive amounts of halothane, negligent fail-
i ure to mix halothane with oxygen, failure to provide
a preoperative anesthesia consultation, and failure to
have an anesthesiologist present during the induction
of anesthesia
RISK REDUCTION
As the cases reported above indicate, there perhaps
is no other medical specialty which calls for the high
degree of vigilance as does anesthesiology. Besides re-
maining vigilant, alert, and aware, what can the
anesthesiologist do to minimize the risk of anesthesia
mishaps?
An article, “Seven Sensible Steps to Safety and Salva-
tion," by Drs. Jeffrey B. Cooper and Ronald S. New-
bower and Charlene D. Long, M.S., published in the
May /June 1980 issue of Malpractice Digest (St. Paul
Fire and Marine Insurance Co.), offered the following
suggestions:
1. Know the equipment. Unfamiliarity with
monitoring equipment was cited as a contributing fac-
tor in a significant number of anesthesia mishaps.
Acquiring a sound theoretical and working knowledge
of all anesthesia apparatus and obtaining appropriate
instruction on the use of new equipment is likely to
reduce error.
2. Identify and eradicate pitfalls. Examine your own
practice to determine whether any frequent albeit
“minor” incidents can be identified. The authors noted
that in two of the hospitals they studied, a pattern of
“syringe swaps” evolved. The errors of selecting the
wrong drug syringes were traced to the lack of a
standard protocol for the sizes and labeling of drug
syringes.
3. Select appropriate “vigilance aids.” Oxygen
monitors, ventilation disconnect alarms, and
temperature monitors may reduce the incidence of
midsurgical procedure mishaps, when the
anesthetist’s concentration or level of awareness may
be somewhat reduced by fatigue.
4. Organize your workspace. Careful arrangement of
drugs and syringes and an organized layout of ap-
paratus are essential.
5. Examine your equipment. Even experienced
anesthesiologists on occasion may fail to note whether
all appropriate apparatus and drugs are available and
to test for proper equipment function. The authors
suggest mandatory use of a written equipment check-
list in every case.
6. Maintain your equipment. Inadequate mainten-
ance of equipment can contribute to human error.
Report any damage or suspicion of damage to ap-
propriately trained and experienced personnel for re-
pair.
7. Identify “predisposing” factors. A few of these
were identified by the authors as inadequate periods
of rest or time off after night call, haste, the presence
of visitors, last minute switching of equipment and
schedules, and emotional stress and interpersonal
conflicts.
The Department of Risk Prevention of the Medical
Inter-Insurance Exchange of New Jersey recently com-
pleted a statistical analysis of anesthesia claims in
which payment has been made to claimants through
December 31, 1983. Although the data base is too
small to recall any statistically significant pattern of
mishaps and their causes, the data suggest the
emergence of possible trends in anesthesia liability.
Out of the 171 paid anesthesia claims, 103 were
solely “tooth cases." The relative frequency of these less
significant claims suggests that increased care with
regard to the patient’s dentition will result in fewer
claims and lawsuits.
The remaining 68 paid cases resulted in payments
to claimants totalling $7.5 million, with an average
VOL. 81— NUMBER 4-APRIL 1984
287
paid indemnity of $1 1 1,384.
The data also revealed that anesthesia claims involv-
ing the use of halothane and claims alleging failure to
intubate (claims which were prevalent in the 1970s)
appear to be abating. It is speculated that the reduc-
tion in the frequency of these claims is directly the
result of the awareness by anesthesiologists of the
magnitude of the problem and their successful risk-
reduction actions in the wake of a pattern of such
serious incidents.
Of the 68 substantial paid claims, two troublesome
areas in anesthesia management emerged. These are:
(1) the improper choice of anesthetic agent or other
drug or medical error; and (2) the administration of
anesthesia in patients who are poor candidates for
surgeiy. Analysis of claims in the latter categoiy sug-
gest that when examined in the cold light of another
day, the anesthesiologist’s decision to clear the patient
for surgery would not have been made.
Lack of communication or lack of effective com-
munication between physicians may lie at the root of
this difficult area of anesthesia practice. Many
anesthesiologists practice in groups where it is routine
for one anesthesiologist to make the preoperative
rounds and for another anesthesiologist to conduct
the anesthesia the next day. All too often there is poor
communication between the evaluating physician and
the physician who actually conducts the anesthesia
The evaluating physician may be well advised that
simply charting his concerns about the patient may
not be sufficient communication when the concern is
of significance and the patient is scheduled for the
operating room. Direct telephone communication may!
be the optimal method of ensuring that the concern;
is acted upon in a timely manner.
Communication between the anesthesiologist and
the surgeon also is an area of serious concern to all!
involved. Often, patients are “tracked” and prepared for
surgery by their surgeon. Given the pressures of hospi-
tal practice, the anesthesiologist occasionally may be
reluctant to call a halt to planned surgeiy. However, the
anesthesiologist must be mindful of the fact that every
member of the health care team is legally responsible
for his own actions. Prudence may dictate that surgeiy
be postponed until additional studies and consul-
tations are available for analysis. Effective communica-
tion with the surgeon in this area may result in fewer
anesthesia incidents to the benefit of all involved.
CONCLUSION
It generally is agreed that anesthesiologists have
done and can do a great deal to reduce the incidence
of serious anesthesia mishaps. Awareness of the prob-
lem areas of anesthesia practice can create a climate
for corrective action. If even a small percent of
anesthesia claims can be avoided, the quality of medi-
cal care will be improved and a significant saving of
insurance dollars can result.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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290
Deaths Related to Narcotics
Overdose in New Jersey
Elizabeth Feuer, m.d., and John French, m.a, trenton*
Abuse of “hits, ” an oral combination of codeine and glutethimide,
has been on the increase. Some features of persons dying of “hits"
overdose are discussed and compared with characteristics of
those dying from overdose of heroin and methadone. The
contribution of alcohol to heroin overdose is stressed.
In early 1982, we studied mor-
tality in New Jersey due to a new
drug combination, known as a
“hit.” A “hit” is an oral combination of 60 mg of co-
deine, usually in the form of aspirin, phenacetin, caf-
feine, and codeine, and 500 mg of glutethimide. Word-
of-mouth reports indicate that this agent has become
increasingly popular in northeastern New Jersey in the
past several years. A report of the results of our study
on the descriptive epidemiologic features has been
published previously.1
For purposes of comparison, we collected data on
deaths related to heroin and methadone. Exam-
ination of the characteristics of persons dying of over-
dose of these three agents forms the basis of this
paper. In addition to the previously presented demo-
graphic characteristics, which we briefly recapitulate,
we now offer data on autopsy and toxicologic findings
which shed further light on the mortality experience
related to these three drugs. We also discuss the issue
of polydrug abuse involving narcotics.
METHODS
The Toxicology Laboratory of the Office of the State
Medical Examiner serves as the sole resource for toxi-
cologic testing for the county medical examiners of the
state. Specimens from approximately 3,000 autopsies
are submitted each year, including all deaths occur-
ring under unknown or suspicious circumstances in
which drug use is suspected to play a role. In such
cases, specimens of tissues and body fluids are sub-
mitted and tested for a wide variety of drugs.
We reviewed the toxicology records for 1980 and
1981, and abstracted information on any deaths with
a positive test for one of the three agents of interest.
Demographic data, county of residence, and toxicologic
data were obtained. Deaths then were classified as
overdose deaths, drug-related deaths, and incidental
deaths (indicating that drugs were unrelated to the
cause of death). Only overdose deaths were examined
in detail, by review of autopsy and toxicologic findings.
Because of the multiplicity of agents found in many
autopsies, classification into categories at times was
arbitrary. We used the following system: her-
oin— presence of morphine-quinine or morphinans-
quinine; methadone — presence of methadone:
“hits” — presence of codeine-glutethimide or
morphinans-glutethimide. These categories, called pri-
mary agents, were structured so as to be mutually
exclusive: individuals with positive findings in more
than one category were classified as mixed. Deaths
involving combinations of primary agents with other
narcotics, such as meperidine and hydromorphone,
were excluded. In addition, drugs such as alcohol.
*From the New Jersey State Department of Health. Cor
respondence may be addressed to Dr. Feuer, Division of
Epidemiology and Disease Control, CN 360, New Jersey State
Department of Health, Trenton, NJ 08625.
VOL. 81— NUMBER 4— APRIL 1984
291
TABLE
1
Demographic
Characteristics of Deaths due to
Hits. Heroin, and Methadone,
1980-1981
Hits
Heroin
Methadone
No.
%
No.
%
No.
%
Total
36
100.0
126
100.0
46
100.0
Male
31
86.1
104
82.5
37
80.4
White
16
44.4
56
44.4
30
65.2
Nonwhite
15
41.7
47
37.3
6
13.0
Unknown
1
0.8
1
2.2
Female
5
13.9
22
17.5
9
19.6
White
1
2.8
5
4.0
7
15.2
Nonwhite
4
11.1
17
13.5
2
4.3
Median Age
Male
21
29
25
Female
31
27
31
!
|
Combined
22
28
26
TABLE
2
Autopsy Findings
in Deaths due to Hits,
Heroin, and Methadone. 1980-1981
Hits
Heroin
Methadone
Findings*
No.
%
No.
%
No.
%
Pulmonary edema
36
100.0
107
94.7
37
94.9
Cerebral edema
19
52.8
63
55.8
19
48.7
Congestion of kidney
21
58.3
57
50.4
15
38.5
Congestion of spleen
20
55.6
49
43.4
12
30.8
Congestion of liver
17
47.2
48
42.5
10
25.6
Fatty liver
1
2.8
14
12.4
3
7.7
Cirrhosis
0
0.0
9
8.0
0
0.0
Gastrointestinal bleeding
2
5.6
3
2.7
2
5.1
Fresh needle marks
1
2.8
54
47.8
3
7.7
"Tracks"
7
19.4
48
42.5
9
23.1
*Pereent refers to percent positive among those reviewed.
barbiturates, or marijuana may have been present. The
presence of these agents did not affect classification
of the case.
RESULTS
Numbers and characteristics of overdose deaths re-
lated to the three primary agents are shown in Table
1. There were 36 deaths related to “hits" overdose, 126
related to heroin overdose, and 46 related to meth-
adone overdose; in addition, there were ten heroin-
methadone mixtures, seven heroin-"hits“ mixtures,
and two methadone-' hits" mixtures. Males
predominated in all three groups; however, the racial
composition of the groups differed somewhat. The
methadone eases showed a marked predominance of
whites (80.4 percent), whereas only 48.4 percent of
heroin deaths and 47.2 percent of “hits" deaths were
white. The median ages of the three groups showed
some variation. The heroin group was the oldest, at 28
years; “hits" deaths had a median age of only 22 years.
The results of the review of the autopsy data are
presented in Table 2. We reviewed the autopsy reports
for 36 "hits" deaths, 1 13 heroin deaths, and 39 meth-
adone deaths, for an overall completion rate greater
than 90 percent. The most common findings related
to viscera] congestion; pulmonary edema, cerebral
edema, and congestion of kidney, liver, and spleen.
Methadone deaths showed these findings less fre-
quently than did heroin or “hits" deaths.
Mention of the presence of fresh needle marks and
of track marks specifically was sought. Both findings
occurred significantly more frequently among heroin
users. Differences in proportions showing fresh needle
marks were particularly striking; fresh marks were
found in 47.8 percent of heroin deaths, but in only 7.7
percent of methadone deaths (x2 = 18.2, P < .001) and
2.8 percent of “hits” deaths (x2 = 21.8, P<.001), imply-
ing that persons dying of methadone and “hits" over-
dose are not current parenteral narcotics users. Dif-
ferences in proportions with venous scars or track
292
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 3
Toxicologic Findings in Deaths due to Hits, Heroin, and Methadone, 1980 1981
Hits
Toxicologic Findings No.
Primary agent alone 25
Primary agent with alcohol 2
with alcohol only 1
with alcohol and depressant 1
with alcohol and other 0
Primary agent with depressant 7
Primary agent with other 2
Total 36
marks also were significant for “hits” (x2 = 5.27, P <
.025) and for methadone (x2 = 3.86, P < .05) compared
to heroin deaths.
An interesting group of findings related to the stig-
mata of alcoholism, particularly fatty liver and cir-
rhosis. Fatty liver was found in 12.4 percent of heroin
deaths, as opposed to 7.7 percent of methadone deaths,
and only 2.8 percent of “hits" deaths. Cirrhosis was
found only in the heroin group, in 8.0 percent of
autopsies. Although these results are not significant
statistically, they are consistent with one another and
show an intriguing pattern.
Toxicologic findings are summarized in Table 3.
Striking differences are found between the groups in
the occurrence of drugs other than the primary agents,
i “Hits” deaths tend to reveal a pattern of little as-
sociated drug use, with 69.4 percent of deaths showing
“hits" as the only agent. This situation is reversed for
the heroin group. Only 13.5 percent of heroin deaths
showed no other drug present. Of the additional drugs
found, alcohol was the most important. Combinations
involving alcohol were found in 69.8 percent of heroin
deaths. Methadone deaths showed intermediate
values, with 34.8 percent of deaths indicating the pres-
ence of alcohol; only 5.6 percent of “hits" deaths
showed alcohol present. These results are significant
(P < .001).
DISCUSSION
The major limitation of this study is its exclusive
focus on mortality data. The implication is strong that
polydrug abuse, especially involving alcohol, increases
a user’s risk of death. However, without data on general
use patterns, it is impossible to state this with certain-
ty. These results merely may reflect use patterns; poly-
drug use may simply be the norm, and the deaths we
have reviewed, rather than indicating a group at
special risk of dying, may be representative of the
broader population of drug users.
We undertook this investigation to examine the ef-
fect of “hits” on drug overdose mortality in New Jersey.
As our analyses advanced, however, we found that
more general patterns of overdose mortality emerged
from the data. Age, race, and sex distributions differ
somewhat among groups. “Hits” deaths tend to be
younger than either methadone or heroin deaths;
methadone deaths show a more marked predominance
Heroin Methadone
%
No.
%
No.
%
69.4
17
13.5
12
26.1
5.6
88
69.8
16
34.8
2.8
75
59.5
6
13.0
2.8
7
5.6
5
10.9
0.0
6
4.8
5
10.9
19.4
12
9.5
8
17.4
5.6
9
7.1
10
21.7
100.0
126
99.9
46
100.0
of whites. Males outnumber females in all three
groups. Whether this reflects heavier usage among
specific population subgroups, or greater susceptibili-
ty to overdose death among certain groups, is impos-
sible to state from these data alone. However, results
of the autopsy review and of the toxicologic review give
further clues.
Users have reported to us that “hits” are an attrac-
tive substitute for heroin, because they are obtained
easily and they are taken orally. Users can avoid the
physical signs of heroin use. This same argument may
apply to oral methadone use as well. It seems probable
that these oral narcotics mainly attract the younger,
less experienced, and perhaps nonhabituated user,
who is at greater risk of death through overdose. This
hypothesis is borne out by the lower prevalence of
track marks among both “hits” and methadone users;
the lower prevalence of fresh needle marks is even
more pronounced, implying that the oral narcotics
users are not concomitant users of heroin.
Both “hits” and methadone contain prescription
pharmaceuticals of a high degree of purity. In contrast,
street heroin has been of low potency in recent years.
It is possible that the potency of “hits” and of meth-
adone is greater than that of currently available heroin,
and that the least experienced users may in fact be
gravitating toward the more potent agents. One point
that is quite clear from the data is that “hits” by them-
selves are potent enough to lead to fatal overdose; near-
ly 70 percent of “hits” deaths had no other agent pres-
ent. Therefore, it cannot be assumed that because a
narcotic is taken orally it is necessarily safe. In con-
trast, only 13.5 percent of heroin deaths involved no
other agent; nearly 87 percent were in combination,
usually with alcohol. This merely may reflect patterns
of use, i.e. that heroin users almost invariably drink
alcohol. However, it may be equally well interpreted as
showing that combined use of heroin and alcohol in-
creases a user’s risk of death.
The autopsy review seems to indicate that al-
coholism is a significant occurrence among heroin
users. The median age of the series was only 28 years,
however, 8.0 percent of those autopsied had cirrhosis.
Fatty liver, indicating more acute alcohol toxicity, was
found in 12.4 percent. Focusing on the problem of
alcohol abuse in persons under treatment for their
heroin problem may be a worthwhile activity.
VOL. 81— NUMBER 4— APRIL 1984
293
One possibility concerning the mortality due to
hits" is that a synergism between the narcotic and the
sedative components was responsible for a more pro-
found central nervous system depression, leading to
death. Review of the toxicologic data on heroin and
methadone lends support to the idea that narcotics
combined with depressants are notably dangerous. For
methadone-related deaths, 52.1 percent involved a
combination including a central nervous system de-
pressant; for heroin, 79.3 percent. Including all three
drugs, and viewing hits as such a narcotic-depressant
combination, 76.9 percent of the narcotics deaths we
reviewed were of this combined type. It appears that
polydrug abuse involving narcotics and alcohol is a
major problem. Correlation of mortality data such as
this with clinical data from physicians involved in the
treatment of drug abusers may be helpful in clarifying
how large a role polydrug use of this type plays in the
current drug scene. Restructuring of treatment pro-
grams better to serve these multiple-drug users may
be worthwhile.
SUMMARY
We report the occurrence of 36 deaths attributable
to “hits" overdose in New Jersey during 1980 to 1981.
During the same period, 126 fatal heroin overdoses
and 46 fatal methadone overdoses were found. Users
dying of “hits" overdose were younger than those dying
of overdose of heroin; autopsies of “hits” and meth-
adone users revealed few signs of intravenous
narcotism. Victims of heroin overdoses showed at post-
mortem an impressive incidence of findings related to
heavy alcohol use. Toxicologic analyses bore out this
association. The dangers of oral narcotic abuse, and
of narcotic-depressant combinations, are highlighted
by these findings.
REFERENCE
1 . Feuer E, French J: Descriptive epidemiology of mortality
in New Jersey due to combination of codeine and
glutethimide. Am J Epidemiol (in press).
ACKNOWLEDGEMENTS
The authors gratefully acknowledge the assistance of Dr.
Robert Goode, the New Jersey State Medical Examiner, and
Dr. Robert Javier, Assistant Director of Toxicology, of the
State Medical Examiner’s Office. We express our appreciation
to Dr. Ronald Altman, Assistant Commissioner of Epidemi-
ology and Disease Control, and to Dr. William Parkin, State
Epidemiologist.
294
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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Computerized Tomography-Guided
Percutaneous Needle Biopsy
Kenneth L. Jewel, m.d., montclair*
A reappraisal of a recently published series confirms the
usefulness and safety of percutaneous needle biopsy with
computerized tomographic guidance. With recent modifications ,
the acceptable accuracy rate of 84 percent has been increased
significantly to 95 percent.
Percutaneous needle biopsy
(PNB) utilizing direct imaging
techniques has been used by
many workers safely and effectively to remove tissue
samples from various organs and anatomic locations
in the body.14 Jewel and Kimler reported their ex-
perience in 120 consecutive eases with a diagnostic
accuracy of 84 percent.5 It has been presumed, with
increasing experience, that many diagnostic and
therapeutic procedures would become safer and more
precise. Since February 1982, 130 additional cases
have undergone PNB. It is the purpose of this report
to analyze the improved success rate and decreased
complication rate, and to compare this series with
previously published material.
METHODS AND MATERIALS
Between Februaiy 1982 and June 1983, 130 con-
secutive cases underwent PNB. Nearly all procedures
were performed utilizing computerized tomographic
(CT) guidance (Figure). Occasionally, if a mass was
large enough, the biopsy was performed with
fluoroscopic assistance after appropriate markers were
placed on the skin. The precise depth was calculated
utilizing CT. Biopsy needle types6 and localization
techniques7 8 have been described previously. All cases
initially were biopsied with a 22-gauge Franseen nee-
dle.** If pathologic material was inadequate, and
clinical and/or technical considerations dictated, an
18-gauge Tru-Cut needle*** was utilized. The
pathological material was removed and was handled as
has been described previously.5
RESULTS
All 130 consecutive eases were analyzed. Approx-
imately 50 percent of the case material consisted of
lung and/or mediastinal biopsies (64 eases) with the
liver and pancreas frequently being biopsied as well
(Table). True positive (TP) results were obtained when
a diagnosis of malignancy was established or when a
specific benign diagnosis was made eytologically or
histologically. False negative (FN) diagnoses were re-
corded when a proved malignant diagnosis was ob-
tained by a subsequent method (thoracotomy,
mediastinoscopy, or exploratory laparotomy) and the
initial PNB had been recorded as negative for malig-
nancy. False positive (FP) diagnoses did not occur in
this series indicating a specificity of 100 percent. True
negative (TN) cases were reported when a benign dis-
ease process was identified by PNB and subsequently
proved by clinical followup and/or other diagnostic
means. The overall accuracy rate in this series was 95
*Dr. Jewel is Director, Department of Radiology, The Moun-
tainside Hospital, Montclair. Correspondence may be ad-
dressed to Dr. Jewel, The Mountainside Hospital, Bay mid
Highland Avenues, Montclair, NJ 07042.
**Cook Incorporated, Bloomington, IN 47402.
***Travenol Laboratories, Incorporated, Deerfield, IL 60015.
VOL. 81— NUMBER 4— APRIL 1984
297
Figure— CT through the upper chest discloses a somewhat
irregularly marginated mass situated slightly to the right of
the sternum (large arrow). The trachea (O) is identified and
the appropriate positioning of a 22-gauge biopsy needle
within the mass clearly is identified (small arrow).
percent.
Complications of the procedure were extremely un-
common and were limited to those patients with lung
and/or mediastinal biopsies. Three cases of minimal
pneumothorax (constituting less than 10 percent of
lung volume) and one case of clinically insignificant
hemothorax were encountered. None of these patients
required chest tube insertion or transfusion and
clinically these complications were considered minor.
DISCUSSION
Since 1979, 250 eases have been referred to the de-
partment of radiology for percutaneous needle biopsy.
Our initial success rate of 84 percent previously has
been described.5 An ongoing analysis of technique and
methodology has been underway with continual re-
finements and adjustments.
The underlying basis for the high rate of success in
this and other series is the use of direct image-guided
technique whether by ultrasound, fluoroscopy, or CT.
While the use of a so-called “fine or skinny” needle is
preferred, there are many instances where insufficien
pathologic material is removed with a 22-gauge needle
A more satisfactory core of tissue can be reeoverei
using a larger cutting needle. By estimating th<
vascularity of a mass to be biopsied as has beef
previously described by Haaga,9 inadvertent biopsy o
a vascular mass with a larger needle can be avoided
A larger sample of tissue helps the pathologist ti
render a correct tissue specific diagnosis more often
In addition, those tissue types which notoriously an
difficult to diagnose (such as lymphoma an<
plasmoeytoma) can be delineated correctly.
A somewhat subjective but important reason for th<
increased accuracy rate in this series concerns th(
greater experience of the interventional radiologis
performing the procedure. In the majority of eases, ;
distinct feel or sensation of “grittiness” is eneounterec
upon entering the abnormal tissue. This is a con
firmatoiy sign of proper needle placement and has
been most helpful. Certainly, with added experience
pathological expertise has increased as well.
Because of the high accuracy rate, an initial negativf
diagnosis with strong clinical suspicion of malignancy
may warrant repeat PNB. This particularly is useful in
elderly and/or debilitated patients where more invasive
procedures may be planned.
With increasing numbers of cases seen as outpa
tients, the technique becomes even more cost effective.
Our complication rate is extremely low with only four
eases encountering any untoward effect (3 percent).
These were minor and required no treatment.
SUMMARY
With minor but important modifications, PNB utiliz-
ing direct image-guided technique has become a major
means of establishing the correct diagnosis at this
institution. The initial accuracy rate of 84 percent de-
scribed in an earlier report has been increased dra-
matically to 95 percent with an even lower complica-
tion rate. This series further confinns the experience
reported in large university centers and illustrates the
usefulness of PNB as a cost-effective, safe, and highly
Anatomic
Site
Number
Biopsied
TP
TN
TABLE
Biopsies
FP
FN
Sensitivity
Percent
Specificity
Percent
Overall
Accuracy
Percent
Chest
64
48
12
0
4
92
100
94
Liver
20
13
5
0
2
87
100
90
Pancreas
16
11
5
0
0
100
100
100
Abdominal or
retroperitoneal mass
(including lymph
node, kidney, adrenal
19
13
5
0
1
93
100
95
Bone
11
8
3
0
0
100
100
100
Total
130
93
30
0
7
93
100
95
TP=true positve; TN=
Sensitivity = (TP)
true negative; FP= false positive; FN = false negative
v i no Specificity = (TN) „ ir>ri Overall accuracy =
(TP+TN)
v i nn
(TP+FN)
(TN + FP)
Total No. of Biopsies
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
298
accurate procedure in community hospitals where in-
erventional radiologic expertise exists.
REFERENCES
1 . Olga AB, Rosenberger A, Peleg H: Fine-needle aspiration
Diopsy of mediastinal masses: Evaluation of 136 experiences.
Am J Roentgenol 140:893-896, 1983.
2. Gross BH, Goldberg HI, Moss AA Harter LP: CT demon-
stration and guided aspiration of unusual adrenal
metastases. J Compnt Assist Tomogr 7:98-101, 1983.
3. Gotenby RA Mulhern CB, Strowitz J: CT-guided per-
cutaneous biopsies of head and neck masses. Radiology
146:717-719, 1983.
4. Harter LP, Moss AA Goldberg HI, Gross BH: CT-guided
fine-needle aspirations for diagnosis of benign and malignant
disease. Am J Roentgenol 140:363-367, 1983.
5. Jewel KL, Kimler S: Percutaneous fine-needle biopsy
using direct imaging techniques. J Med Soc NJ 79:731-733,
1982.
6. Haaga JR LiPuma JP, Bryan PJ, Balsara VJ, Cohen AM:
Clinical comparison of small and large calibre cutting needle
for biopsy. Radiology 146:665-667, 1983.
7. Ferrucci JR Wittenberg J: Computed tomography biopsy
of abdominal tumors: Aids for lesion localization. Radiology
129:739-744, 1978.
8. Haaga JR New technique for computed tomography
guided biopsies. Am J Roentgenol 133:633-641, 1979.
9. Haaga JR Vanek J: Computed tomography-guided liver
biopsy using the Menghini needle. Radiology 133:405-408,
1979.
VOL 81— NUMBER 4— APRIL 1984
299
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newhat variable INDERAL has
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In angina pectoris, propranolol generally reduces tl
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damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
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Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
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Propranolol is not significant! tyzable.
INDICATIONS AND USAGE, i .rteission: INDERAL LA is indicated in the manage-
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Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the Jong-term management of patients with angina pectoris.
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The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
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angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
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the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
mncD^ee WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of diqitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking therap
prior to major surgery is controversial It should be noted, however, that the impaired ability c
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesi
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of beta
receptor agonists and its effects can be reversed by administration of such agents, e g
dobutamine or isoproterenol However, such patients may be subject to protracted sever,
hypotension Difficulty in starting and maintaining the heartbeat has also been reported witl.
bGt3 blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the ap
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes) c,
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be morr||
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS Beta blockade may mask certain clinical signs of hyperthyroidism I
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptom'
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function tests
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have beei
reported in which, after propranolol, the tachycardia was replaced by a severe bradycardi;
requiring a demand pacemaker In one case this resulted after an initial dose of 5 me
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with impairec
hepatic or renal function INDERAL is not indicated for the treatment of hypertensive
emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Patient:;
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal maj
lead to a return of increased intraocular pressure
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart disease I
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as reser
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blocking action may produce an excessive reduction of resting sympathetic nervous activity
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostatic
hypotension.
Carcinogenesis, Mutagenesis, Impairment ot Fertility: Long-term studies in animals have
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studies ir
‘ 1 mg/kg/day, there was no evidence of signif icanl
lated tumongenic effects at any of the dosage
not show any impairment of fertility that was
DERAL has been shown to be embryotoxic in
ir than the maximum recommended human dose
leqCtawsafid wdfPiPffrblled studies in pregnant women INDERAL should
nancy only if the potential benefit justifies the potential risk to the fetus
INDERAL is excreted in human milk Caution should be exercised when
an
s in children have not been established
: effects have been mild and transient and have
nsiol
aynau<
Central Nervous Systei
lassitude, weakness, fatigu
pt^st've heart failure, intensification of AV block; hypo-
lcBi°IMflljPurDLlra: arterial insufficiency, usually of the
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
ot having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g,, chronic bronchitis, emphysema)
m lIl^lo0NCH0SPASTIC D|SEASES SHOULD IN GENERAL NOT RECEIVE BETA
dLUCKLHS INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
eadedness; mental depression manifested by insomnia. j-J
'ersible mental depression progressing to catatonia, visual 1 1
disturbances, hallucinations; an acute reversible syndrome characterized by disorientation for
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, and!
decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhea/
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with aching/
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic1'
purpura.
Auto-Immune In extremely rare instances, systemic lupus erythematosus has beenij
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo-[
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous reactions ;!|
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practolol)
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride in a
sustained-release capsule for administration once daily. If patients are switched from INDERAL
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeutic j|
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute for I
INDERAL. INDERAL LA has different kinetics and produces lower blood levels Retitration may
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interval >
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 mg.
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may be'
increased to 120 mg once daily or higher until adequate blood-pressure control is achieved
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 640
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variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL LA
once daily, dosage should be gradually increased at three to seven day intervals until optimum
response is obtained Although individual patients may respond at any dosage level, the
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value and
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosaqe qradually over a period of a few weeks
(see WARNINGS).
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL LA
once daily. The usual effective dose range is 160-240 mg once daily The dosage may be j
increased gradually to achieve optimum migraine prophylaxis If a satisfactory response is not
obtained within four to six weeks after reaching the maximum dose, INDERAL LA therapy
should be discontinued It may be advisable to withdraw the drug qradually over a period of ,
several weeks.
DcnIZ^£Er?TR0PHIC SUBA0RT|C STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group are too
limited to permit adequate directions for use.
‘The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratories.
8950/284
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AYERST LABORATORIES
New York, N Y. 10017
302
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Premenstrual Syndrome
Fact or Fantasy?
Marco A. Pelosi, m.d., bayonne*
Media attention on premenstrual syndrome (PMS) has stimulated
patients to demand attention from unsympathetic physicians.
Patients are relieved to know that PMS is a real entity with a
possible physiologic basis. The ultimate medical and legal
acceptance of PMS could have some adverse effects for women.
Premenstrual syndrome (PMS) or
premenstrual tension (PMT)
has been “rediscovered" by the
press. Several legal eases, publicized in England, have
drawn considerable attention to PMS.1 An inordinate
number of patients suffering from the condition,
whose symptoms often were ascribed to emotional fac-
tors, are demanding needed attention from allegedly
unsympathetic physicians. We have experienced an
unusual increase in the number of patients referred
with PMS by primaiy physicians and psychiatrists.
Patients often are relieved to learn that a physiological
basis for the condition exists.
The current interest in PMS has led to the creation
of premenstrual syndrome clinics in this country be-
cause: of the emergence of women’s organizations de-
voted to the understanding and treatment of PMS, of
the case reports of PMS as a gynecological problem,
and of the recent use of PMS as a legal defense.2
DEFINITION
The symptoms of premenstrual syndrome start dur-
ing the luteal phase of the menstrual cycle, i.e. from
14 days to 1 day before menstruation. There must be
a symptom-free period of at least one week after
menstruation stops. The diagnosis of PMS should be
reserved until other pathophysiological and psycho-
logical conditions have been ruled out. The most fre-
quent symptoms occur cyclically before menstruation
onset and disappear during menstruation (Table 1).
PMS may occur at any time from menarche to
menopause and will affect 30 percent of females in a
relatively severe form at some time in their lives. Symp-
tomatology may vaiy from patient to patient and may
differ in intensity from one menstrual cycle to the next.
Occasionally, PMS becomes more severe with age as
some muscle tissue is replaced by fat providing a more
efficient aromatization of estrogen. This phenomenon
may raise the estrogen/progesterone ratio and lead to
more severe symptoms.2
The definition of PMS is confused by the broad
range, variable severity, and wide prevalence of symp-
toms, which raises questions of what is normal and
what is baseline. The fact that many otherwise healthy
women experience premenstrual discomfort, suggests
that the cause is physiologic, but the rare occurrence
of incapacitating symptoms suggests that the con-
dition sometimes is pathologic.3 The recent lesson
learned about “primaiy or idiopathic" dysmenorrhea
should not be forgotten. Not too long ago, lack of knowl-
edge led us to conclude that dysmenorrhea implied
either pelvic pathology or emotional instability. Now,
it is well established that primaiy dysmenorrhea is a
physiologic, although uncomfortable, response of the
*Dr. Pelosi is Clinical Associate Professor, Obstetrics and
Gynecology, UMDNJ-New Jersey Medical School. Cor
respondence may be addressed to Dr. Pelosi, Pelosi Women's
Medical Center, 738 Kennedy Boulevard, Bayonne. NJ 07002.
VOL 81— NUMBER 4— APRIL 1984
303
TABLE 1
Symptoms oj Premenstrual Syndrome
Abdominal bloating
Acne
Aggression
Anxiety
Breast engorgement
and tenderness
Change in bowel habits
Change in libido
C iy*ng spells
Depression
Edema
Fatigue
Food cravings
Headache
Hot flushes
Heaviness
Increased appetite
Insomnia
Irritability
Leg heaviness
Lethargy
Loss of concentration or im-
paired coping ability
Mood swings
Muscle and/or joint pain
Nausea
Peripheral edema
Poor coordination/clumsiness/
tendency to accidents
Pelvic pain
Pruritus
Rhinitis
Skin disorders
Tension
Thirst
Weigh! gain
normal uterus to normal prostaglandins and not a
psychogenic reaction. The notion that women with
PMS are emotionally unstable suggests an admission
of ignorance of the underlying physiology, which has
led many physicians to doubt the existence of PMS.
INCIDENCE
The exact incidence of PMS is difficult to evaluate.
Lauersen and Graves reviewed the subject and found
the prevalence of PMS in otherwise healthy women
ranged from 31.9 percent to 40 percent.2 When PMS
was defined as any combination of emotional or physi-
cal complaints that occurred before menstruation and
disappeared toward the end of menstruation, only 3
percent of normal women escape the diagnosis of PMS.
Consequently, it is essential to distinguish between
patients with premenstrual changes considered toler-
able or normal and those with severe symptoms.
Premenstrual syndrome has a definite impact on work
efficiency and absenteeism: among 1,500 women in
one plant, 36 percent sought sedation in the
premenstrual week.
ETIOLOGY
The exact etiology of PMS still is not known. Un-
fortunately, the undetermined cause of PMS is the
single most important issue preventing the develop-
ment of appropriate treatment. Etiological hypotheses
have been numerous and varied (Table 2).
DIAGNOSIS AND CLASSIFICATION OF SYMPTOMS
The great variety of symptoms has confused the
clinical picture of PMS. Recently, the problem has been
simplified by Abraham, who divided the symptoms
into four groups according to the major symptoms:20
1. PMT-A: Anxiety, irritability, and mood swings.
2. PMT-D: Depression, insomnia and confusion.
3. PMT-H: Edema, weight gain, abdominal bloating,
headache, breast engorgement and tenderness, and
peripheral edema.
4. PMT-C: Increased appetite and craving for sweets
and other foods.
The physician must be willing to accept the patient’s
symptoms as real and to investigate possible causes.
Physical factors must be ruled out before attributing
PMS to an emotional problem. A detailed medical,
menstrual, sexual, and psychological history is
imperative. A menstrual calendar should be reviewed.
A general physical examination and a careful pelvic
examination is mandatory with attention to ovarian
masses, myomas, pelvic inflammatory disease, and
endometriosis. Breast examination is important. When
needed, ultrasonography, x-rays, mammography, CAT
scan, and laparoscopy should be performed. When the
Papanicolaou (pap) smear is taken, vaginal cytology to
evaluate the hormonal status (maturation index)
should be done. Primary or secondary dysmenorrhea
often is associated with PMS. Cyclical depression with
premenstrual onset, followed by prolonged depression,
must be differentiated from PMS. Laboratory
evaluation should include hemogram, blood chemistry,
folliculo-stimulating hormone/luteinizing hormone
(FSH/LH), serum estradiol, serum progesterone, serum
prolactin, and thyroid profile. These tests should be
performed during the premenstrual period, (one to
seven days prior to menstruation) and/or at the time
the symptoms are more severe. The foreknowledge of
the patient’s premenstrual hormonal status offers
invaluable information, which usually is needed for
treatment of the different types of PMS.2
The correlation between the categories of PMS with
their pathophysiologic changes and suggested
treatments are presented in Table 3.
TREATMENT
Since the cause of PMS is unknown, a number of
empirical and even controversial treatments have been
used (Table 3). Therapy must be individualized and
include emotional support and acknowledgment of the
reality of the patient’s physical and psychological
symptoms. On the other hand, both the patient and
the physician should avoid blaming PMS for unrelated
dysfunctions.
A general approach which has proved to be
successful should be tried in all PMS patients.2 The
following program might avoid the need for medical
therapy in approximately 40 percent of patients:
1. Reduction of calorie intake because increased
body weight and the conversion of fatty tissue to
estrogen may exacerbate the symptoms. During the
premenstrual period, reduction in salt intake is
advised to prevent water retention. A low-sugar, high-
protein diet divided into five or six small feedings
seems to benefit many patients. Some patients may
need to remain on a hypoglycemic diet to reduce blood
sugar fluctuations.
2. Vitamin B6 (pyridoxine), 50 to 800 mg/day, has
produced marked improvement in combination with
a high-protein, low-salt, and low-sugar diet. The
vitamin regulatory role in brain monoamine
production (acting as a coenzyme in the biosynthesis
of dopamine and serotonin) is thought to be effective
in treating such symptoms of PMS, as depression,
tension, anxiety, aggression, or irritability.
3. Increase physical activity and exercise in order to
promote metabolism and rebuild muscle mass.
Athletes tend to experience less premenstrual tension
and fewer headaches than nonathletes, but not less
304
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 2
Etiology of Premenstrual Syndrome*
Author
Year
Theory
Frank4
1931
Decreased renal clearance.
Sweeney3
1934
Disturbance of the sympathetic nervous system.
Israel9
1938
Defective luteinization resulting from progestin deficiency or relative
hyperestrogenemia.
Thom, et al.7
1938
Decreased urinary output, with retention of sodium and chloride.
Greenhill and Freed8
1940
Estrogen-induced salt and water retention.
Biskind9
1943
Estrogen excess due to decreased liver clearance. Vitamin B recommended.
Billig and Spaulding10
1947
Hyperinsulinism.
Stieglitz and Kimble11
1949
Endometrial toxin which could be treated with ammonium nitrate.
Morton12
1950
Increased carbohydrate tolerance and abnormal glucose tolerance curve.
Recommended vitamin B complex, high-protein, low-salt, low-sugar
diet.
Bickers and Woods13
1951
Vasopressin-induced water intoxication.
Greene and Dalton14
1953
Introduced for the first time the concept of a syndrome. Progestin therapy.
Rees 1 5
1953
Found psychotherapy of limited value and recommended individual
therapy.
1954 Found flat glucose tolerance curves during the luteal phase.
1969 They found no allergic component to sex hormones in PMS.
1971 They found no allergic component to sex hormones in PMS.
1981 Multifaceted psychoneuroendocrine disorder involving a dysfunction in the
hypothalamus, pituitary, and ovarian axis. PMS is due to an atypical
release of/or a sensitivity to the neurointermediate lobe peptide alpha
melanocyte-stimulating hormone and beta-endorphins during the
luteal phase.
* Based on Shangold's Review3
edema. Significant heaviness, lethargy, and
impairment of performance before menses may persist
despite exercise.44
4. Avoid situations and people who are upsetting;
get plenty of sleep.
5. Attempt to deal with stress more effectively.
Psychotherapy alone has proved to be of limited value.
HORMONES AND OTHER DRUGS
Patients with PMS who do not respond to the above
program are candidates for medical treatment. If blood
tests indicate a hormonal imbalance (usually a
decrease in progesterone and estradiol ratio), natural
progesterone vaginal suppository therapy might be
successful. Normally, approximately 200 mg/day of
progesterone is produced during the luteal phase but
because of the loss of absorption through the vaginal
mucosa, 200 mg to 400 mg b.i.d. is recommended.2
Progesterone therapy in combination with counseling
and the general program may eliminate PMS
symptoms in approximately 80 percent of the
patients.2 Where a significant hormonal imbalance is
not present and the symptoms are severe and/or
persistent and other treatments failed, progesterone
therapy may be tried. There are no oral natural
progesterone tablets, since the hormone would be
destroyed in the gastrointestinal tract. It is advisable
to instruct the patients to insert the suppositories
high in the posterior vaginal fornix and to stay in the
supine position for several minutes after insertion to
avoid leakage of the medication. Observations that
PMS symptoms are maximal as progesterone levels fall
may indicate that progesterone withdrawal, rather
than progesterone deficiency, causes PMS. After tubal
sterilization, some patients notice an increase of PMS
symptoms. A decrease in the blood supply of the ovary,
producing an abnormal luteal function with deficiency
in progesterone output, may be the etiologic factor.2
Natural progesterone vaginal suppositories are not
readily available; however, they can be prepared by a
local pharmacy or ordered from a pharmaceutical
manufacturer. Suppositories also are available from
PMS clinics. Parenteral progesterone is not desirable
because of its long-acting effects and interference with
menstruation. No major side effects have been found
to be associated with the cyclic use of progesterone
suppositories, but the following may occur: tiredness,
euphoria, breast engorgement, initial flush and feeling
of warmth after insertion of suppositories, and nausea.
In these eases, reduced dosage is advised.
Synthetic hormones, such as medroxyprogesterone
(Provera") and dydrogesterone, have not been found to
be as effective, and occasionally may exacerbate the
symptoms.2 Uncontrolled studies have reported
improved PMS symptoms with norethisterone,
dimethisterone, and ethisterone.45
Mukherjee16
Jones and Gordon17
Farah and Shbaklu18
Reid and Yen19
VOL. 81— NUMBER 4— APRIL 1984
305
Syndrome
TABLE 3
Types of Premenstrual Treatments
Pathophysiology
Suggested Treatments
PMT-A: Anxiety,
irritability, and mood
svvi ngs.
PMT-D: Depression,
insomnia, and
confusion.
• Elevated estrogen/progesterone ratio in
the luteal phase.21
• Plasma MAO activity relates directly to
the plasma progesterone/estradiol ratio
and is inversely proportional to plasma
estradiol level.22
• Estrogen decreases MAO activity, while
progesterone increases it.23
• Reduced RBC magnesium concentration
is present in PMT-A.24
• Magnesium and pyridoxine are needed
for synthesis of brain dopamine; symp-
toms of PMT may result from their defi-
ciency.25,26
• Low brain concentration of nor-
epinephrine.27
• Lower serum estradiol levels and higher
serum progesterone levels occur during
the luteal phase.28
• Progesterone therapy increases MAO ac-
tivity' and lowers catecholamine concen-
tration. Progestins enhance metabolism
of catecholamines.
• Estrogen therapy decreases MAO activity
and estrogen plus progesterone raises
the MAO activity' above the estrogen ther-
apy level.29
• General program: diet modification (de-
creased calories, high-protein, low-salt,
low-sugar diet, during the premenstrual
period); exercise; counseling.
• Vitamin B6 (50 to 800 mg/day) (to de-
crease serum estradiol and increase
p roges t e ro n e. ) 25 26,43
• Natural progesterone suppositories. 200
to 400 mg/day, b.i.d. 10 to 14 days prior
to menstruation, discontinue at time of
expected period.2,41
• Oral contraceptives.2
• Tranquilizers. 3
• General program.
• Vitamin B6, vitamin B complex.
• Antidepressive medication, sleeping
drugs, psychotherapy, and counseling.
• Progesterone suppositories or oral con-
traceptives, most likely will not be effec-
t ive.
PMT H: Edema weight
gain, abdominal
bloating, headache,
peripheral edema, breast
engorgement, and
tenderness.
• Increased aldosterone (premenstrually).
• Higher levels of 1 1 desoxyeorticoste-
rone during the luteal phase. Both ster-
oids produce fluid retention.30 32
• Dopamine inhibits aldosterone syn-
thesis.3334
• PMS patients have higher prolactin
levels. Bromocriptine, a dopamine
agonist, improves PMS symptoms.35 38
PMT-C: Increased
appetite and craving for
sweets and other foods.
• Reduction of insulin receptors on mono-
cytes during the luteal phase, produces
a decreased insulin sensitivity and de-
creased carbohydrate tolerance.39 PMS-C
patients have flat glucose tolerance
before menses. 1240 The impaired glucose
tolerance during the luteal phase which
results in a rebound increased glucose
tolerance during the premenstrual phase
is believed to be the cause of the PMS-
C symptoms. Reactive hypoglycemia is
unlikely to be the etiology of PMS-C since
it usually is asymptomatic and can be
detected in normal women; the symp-
toms are not relieved by eating and are
rarely' confined to times when
hypoglycemia is likely to be maximal.2
• General program.
• Low-salt diet.2,3
• Diuretics: spironolactone (antagonizes
aldosterone action and inhibits steroid
genesis) 25 mg. b.i.d. during the days of
expected symptoms or 50 mg/day on
symptomatic premenstrual days only
and increasing to 50 mg/day throughout
the cycle.242
• Bromocryptine tablets (Parlodel") 2.5 mg
b.i.d. 10 to 14 days prior to menstruation
in patients with increased prolactin
levels 3538
• Combination of vitamin B6 and vitamin
A (to oppose thyroid hyperfunction or to
create a direct antiestrogenic and
diuretic effect). Progesterone therapy
may be necessary if no improvement is
noticed.2
• General program.
• Low-sugar, low-salt, high-protein diet
(five or six small meals/day).
• Avoid alcohol and caffeine during the
premenstrual period.
• Vitamin B6, vitamin B complex.
• Progesterone therapy may be necessary.2
306
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The value of diuretics in the treatment of PMS still
is controversial, but a smaller number of controlled
studies indicate the usefulness of this approach. The
usefulness of chlorthalidone, metolazone, furosemide,
or spironolactone in conventional dosages during the
Ijluteal phase of the cycle has been advocated;
spironolactone seems to be favored.342
Evaluation of the effect of oral contraceptives on
PMS is difficult. A few patients report improvement
with birth control pills, possibly due to reduction in
hormonal fluctuation during the cycle. The more
progestogenie pills are associated with fewer PMS
symptoms. If no side effects are present and the patient
needs contraception, it generally is concluded that this
approach is useful. In some patients, symptoms of
PMS may be exacerbated.2
Bromocriptine (Parlodel")- though used for treat-
ment of all PMS symptoms, offers conflicting results
even in well-controlled studies. In general, the drug has
proved efficacy in treating breast complaints, but does
not help with fluid retention or other symptoms. It
probably should be reserved for the PMS patient with
an increased prolactin level. If this does not eliminate
symptoms, combination with B6 and progesterone
therapy may be necessary.2
Antigonadotropin drug, danazol (Danocrine"), has
been considered a logical choice for treating PMS. Gen-
erally, significant improvements in breast symptoms
have been shown with only slight improvement in the
other symptoms. Danazol" may be considered for pa-
tients in whom other forms of therapy have failed.
Because of possible annoying side effects, Danazol" in
a dose of 200 mg t.i.d. or q.i.d. should be prescribed
in patients who had a combination of PMS and en-
dometriosis and/or fibrocystic breast disease. The pa-
tient can remain on this medication for 6 to 12
months.
Some patients may need modification of treatment
from time to time. It should be kept in mind that all
treatment regimens for PMS remain controversial.
Though some drugs certainly are useful in relieving
some symptoms, several studies of PMS have shown
a strong placebo effect. Unfortunately, the majority of
PMS treatment regimens fail to compare drugs used
with placebo, consequently, interpretation of the avail
able data is difficult.
LEGAL CONSIDERATIONS
The press focused attention of PMS as a legal de-
fense in 1982 when two European women were ac-
quitted of murder. Currently, the use of PMS as a legal
defense, to limit criminal responsibility, is being as-
serted in several courts in the United States. Presently,
in the United States, the only disease process that
affords a defense is mental illness. It must be estab-
lished in most states that the illness was of such a
nature to negate or diminish judgmental capacity so
that the person did not know right from wrong or had
an irresistible impulse to commit the crime. It is
arguable that PMS can produce such a result.46
To use PMS as a legal defense, three criteria must
be met: the court must recognize PMS as an illness;
it must be proved that the person suffers from PMS;
and the defense must establish a link between the
PMS and the crime. At the present time, at least in this
country, to meet any of these criteria is not an easy
task. Legally, it is difficult to prove that PMS really is
a well-established disease, and if it is, whether or not
one suffers from it. PMS currently does not fit clearly
into a strictly physiological or mental category (insani-
ty plea).45 Thus, the use of PMS to decrease responsi-
bility for a person’s actions still is a moot point.
SUMMARY
Current investigation should enhance our knowl
edge and understanding about PMS. Whatever cause
is suspected, therapy must be individualized for use
of one regimen as a “cure-all" usually will be unsuc-
cessful. Patients with PMS no longer may be ignored
by the physician; their symptoms should not be dis-
missed as imaginary or accepted as an unchangeable
aspect of being female.
The universal acceptance of PMS as a well-estab-
lished medical condition, however, could have adverse
social, cultural, job- related, and legal ramifications for
women and could prevent them from achieving
equality. As an accepted legal defense, it could have
negative implications for females in custody cases and
divorce proceedings and might even justify violence
against women (as in plea of self-defense). Several fem-
inist groups are pleased that physicians are taking
PMS seriously, but have a growing concern that
previous prejudices against women maybe resurrected
and may prevent equality.45
REFERENCES
1. Dalton K: Cyclical criminal acts in premenstrual syn-
drome. Lancet 2:1070, 1980.
2. Lauersen NH, Graves ZR. A new approach to
premenstrual syndrome. Female Patient 8:41, 1983.
3. Shangold MM: PMS is real, but what can you do about
it? Contemporary Ob/Gy n 19:251, 1982.
4. Frank R: The hormonal causes of premenstrual tension.
Arch Neurol Psychiatr 26:1053, 1931.
5. Sweeney J: Menstrual edema. JAMA 103:234, 1934.
6. Israel SL: Premenstrual tension. JAMA 110:1721. 1938.
7. Thorn G, Nelson K, Thorn D: A study of the mechanism
of edema associated with menstruation. Endocrinology
22:155, 1938.
8. Greenhill J, Freed S: The mechanism and treatment of
premenstrual distress with ammonium chloride. En-
docrinology 26:529, 1940.
9. Biskind M: Nutritional deficiency in the etiology of
menorrhagia, metrorrhagia, cystic mastitis, and
premenstrual tension: Treatment with vitamin B complex. J
Clin Endocrinol Metab 3:227, 1943.
10. Billig G, Spaulding C: Hyperinsulinism of menses. In-
dustrial Med 16:336, 1947.
1 1. Stieglitz E, Kimble S: Premenstrual intoxication. Am J
Med Sci 218:616, 1949.
12. Morton J: Premenstrual tension. Am J Obstet Gynecol
60:343, 1950.
13. Bickers W, Woods M: Premenstrual tension; its relation
to abnormal water storage. N Engl J Med 245:453. 1951.
14. Greene R, Dalton K: The premenstrual syndrome. Br
Med J 1 : 1 007, 1 953.
15. Rees L: The premenstrual tension syndrome and its
treatment. Br Med J 1:1014, 1953.
16. Mukheijee C: Premenstnial tension: A critical study of
the syndrome. J Indian Med Assoc 24:82, 1954.
17. Jones W. Gordon W: Autoimmune progesterone
eczema — an endogenous progesterone hypersensitivity. Arch
Dermatol 99:57, 1969.
18. Farah F. Shbaklu A: Autoimmune progesterone
urticaria. J Allergy Clin Immunol 48:257, 1971.
19. Reid R, Yen S: Premenstrual syndrome. Am J Obstet
VOL. 81— NUMBER 4— APRIL 1984
307
Gynecol 139:85, 1981.
20. Abraham G: Premenstrual tension, in Current Prob-
lems in Obstetrics and Gynecology. Chicago, IL, Yearbook
Medical Publishers, 1981, pp 1-39.
21. Backstrom T, Carstensen H: Estrogen and
progesterone in plasma in relation to premenstrual tension.
J Steroid Biochem 5:257, 1974.
22. Briggs M, Briggs M: Relationship between monamine
oxidase activity and sex hormone concentration in human
blood plasma. J Reprod Fertil 29:447, 1972.
23. Holzbauer M, Youdim M: The estrous cycle and
monamine oxidase activity. Br J Pharmacol 48:600, 1973.
24. Abraham G, Lubran M: Serum and red cell magnesium
levels in patients with premenstrual tension. Am J Clin Nutri-
tion 34:2364, 1981.
25. Abraham G, Hargrove J: Effect of vitamin B6 on
premenstrual symptomatology in women with premenstrual
tension syndrome: A double-blind crossover study. Infertility
3:155, 1980.
26. Hargrove J, Abraham G: Effect on vitamin B6 on in-
fertility in women with the premenstrual tension syndrome.
Injertility 2:315, 1979.
27. Robinson D: Changes in monamine oxidase and
monamines with human development and aging. Fed Proc
34:103, 1975.
28. Abraham G, Eisner C, Lucas L: Hormonal and behav-
ioral changes during the menstrual cycle. Senologia 3:33,
1978.
29. Klaiber E, Kobayaski Y, Broverman D, et al.: Plasma
monamine oxidase activity in regularly menstruating women
and in amenorrheie women receiving cyclic treatment with
estrogens and progestin. J Clin Endocrinol 33:630, 1971.
30. Schwartz U, Abraham G: Corticosterone and
aldosterone levels during the menstrual cycle. Obstet Gynecol
45:339, 1975.
3 1 . Perrini A, Piliego N: The increases of aldosterone in the
premenstrual syndrome. Minerva Med 50:2897, 1959.
32. Manlimos FS. Maroulis GB, Abraham GE: Radio-
immunoassay of plasma 1 1-desoxyeorticosterone. Anal Lett
8:931, 1975.
33. McKenna T, Island D, Nicholson W, et al.: Dopamine!
inhibits angiotensin stimulated aldosterone biosynthesis in
bovine adrenal cells. J Clin Invest 64:287, 1979.
34. North R McCallum R Contino C, et al.: Tonic
dopaminergic suppression of plasma aldosterone. J Clin En
docrinol Metcib 51:64, 1980.
35. Halbreich U, Assael M, Ben-David M, et al.: Serum-
prolactin in women with premenstrual syndrome. Lancet
2:654, 1976.
36. Carroll B, Steiner M: The psychobiology of
premenstrual dysphoria The role of prolactin. Psy
choneuroendocrinology 3:171, 1978.
37. Andersch B, Hahn L, Wendestam C, et al.: Treatment
of premenstrual tension syndrome with bromocriptine. Acta
Endocrinol (suppl 88) 216:165, 1978.
38. Eisner C, Buster J, Schindler R et al.: Bromocriptine
in the treatment of premenstrual tension syndrome. Obstet
Gynecol 56:723, 1980.
39. DePirro R Fusco A, Bertoli A, et al.: Insulin receptors!
during the menstrual cycle in normal women. J Clin En-
docrinol Metab 47:1387, 1978.
40. Morton J, Addison J, Addison R et al.: A clinical study
of premenstrual tension. Am J Obstet Gynecol 65:1 182, 1953.
41. Dalton K: The Premenstrual Syndrome and
Progesterone Therapy. London, William Heinemann Medical
Books, Ldt., and Chicago, IL, Year Book Medical Publishers,
Inc., 1977.
42. Hendler N: Spironolactone for premenstrual syndrome.
Female Patient 5:17, 1980.
43. Abraham G, Schwartz U, Lubran M: Effect of vitamin
B6 on plasma and red blood cell magnesium levels in
premenopausal women. Ann Clin Lab Sci 11:333, 1981.
44. Timonen S, Procope B: Premenstrual syndrome and
physical exercise. Acta Obstet Gynecol Scand 50:331, 1971.
45. Premenstrual syndrome. Is it all in her head? Sexual
Medicine Today 7:6, 1983.
308
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
An added complication...
in the treatment of bacterial bronchitis*
Briel Summary Consult the package literature tor prescribing
information
Indications and Usage: Ceclor® (cefaclor. Lilly) is indicated in the
treatment ot the following infections when caused by susceptible
strains of the designated microorganisms
Lower respiratory infections, including pneumonia caused by
Streptococcus pneumoniae (Diplococcus pneumoniae), Haemophilus
influenzae, andS pyogenes (group A beta-hemolytic streptococci)
Appropriate culture and susceptibility studies should be performed
to determine susceptibility of the causative organism to Ceclor
Contraindication: Ceclor is contraindicated in patients with known
allergy to the cephalosporin group of antibiotics
Warnings: IN PENICILLIN-SENSITIVE PATIENTS. CEPHALOSPORIN
ANTIBIOTICS SHOULO BE ADMINISTERED CAUTIOUSLY. THERE IS
CLINICAL AND LABORATORY EVIOENCE OF PARTIAL CROSS-
ALLERGENICITY OF THE PENICILLINS AND THE CEPHALOSPORINS
AND THERE ARE INSTANCES IN WHICH PATIENTS HAVE HAD
REACTIONS, INCLUDING ANAPHYLAXIS, TO BOTH ORUG
CLASSES
Antibiotics, including Ceclor, should be administered cautiously to
any patient who has demonstrated some form of allergy, particularly
to drugs.
Pseudomembranous colitis has been reported with virtually all
broad-spectrum antibiotics (including macrolides, semisynthetic
penicillins, and cephalosporins), therefore, it is important to consider
its diagnosis in patients who develop diarrhea in association with the
use of antibiotics. Such colitis may range in severity from mild to
life-threatening
Treatment with broad-spectrum antibiotics alters the normal flora
of the colon and may permit overgrowth of Clostridia Studies
indicate that a toxin produced by Clostridium ditticile is one primary
cause of antibiotic-associated colitis
Mild cases of pseudomembranous colitis usually respond to drug
discontinuance alone. In moderate to severe cases, management
should include sigmoidoscopy, appropriate bacteriologic studies, and
fluid, electrolyte, and protein supplementation When the colitis does
not improve after the drug has been discontinued, or when it is
severe, oral vancomycin is the drug of choice for antibiotic-
associated pseudomembranous colitis produced by C ditticile. Other
causes of colitis should be ruled out
Precautions. General Precautions— If an allergic reaction to Ceclor
occurs, the drug should be discontinued, and, if necessary, the
patient should be treated with appropriate agents, e g , pressor
amines, antihistamines, or corticosteroids
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms. Careful observation of the patient is
essential If superinfection occurs during therapy, appropriate
measures should betaken
Positive direct Coombs' tests have been reported during treatment
with the cephalosporin antibiotics. In hematologic studies or in
transfusion cross-matching procedures when antiglobulin tests are
performed on the minor side or in Coombs' testing of newborns
whose mothers have received cephalosporin antibiotics before
parturition, it should be recognized that a positive Coombs' test may
be due to the drug
Ceclor should be administered with caution in the presence of
markedly impaired renal function Under such conditions, careful
clinical observation and laboratory studies should be made because
safe dosage may be lower than that usually recommended
As a result of administration ol Ceclor, a false-positive reaction for
glucose in the urine may occur. This has been observed with
Benedict's and Fehling's solutions and also with Clinitest® tablets but
not with Tes-Tape* (Glucose Enzymatic Test Strip, USP, Lilly) '
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history ol gastrointestinal disease, particularly
colitis
Usage in Pregnancy— Pregnancy Category B— Reproduction
studies have been perlormed in mice and rats at doses up to 12 times
the human dose and in ferrets given three times the maximum human
dose and have revealed no evidence of impaired fertility or harm to
the fetus due to Ceclor There are, however, no adequate and
well-controlled studies in pregnant women Because animal
reproduction studies are not always predictive of human response,
this drug should be used during pregnancy only if clearly needed
Nursing Mothers — Small amounts of Ceclor have been detected in
mother's milk following administration of single 500-mg doses
Average levels were 0.18, 0 20, 0 21 , and 0 16 mcg/ml at two, three,
four, and five hours respectively. Trace amounts were detected at one
Some ampicillin-resistant strains of
Haemophilus influenzae— a recognized
complication of bacterial bronchitis*-are
sensitive to treatment with Ceclor.1 6
In clinical trials, patients with bacterial bronchitis
due to susceptible strains of Streptococcus
pneumoniae, H, influenzae, S. pyogenes
(group A beta-hemolytic streptococci), or multiple
organisms achieved a satisfactory clinical
response with Ceclor.7
Cefaclor
Pulvules®, 250 and 500 mg
hour The effect on nursing infants is nof known Caution should be
exercised when Ceclor* (cefaclor, Lilly) is administered to a nursing
woman
Usage in Children— Safety and effectiveness ol this product for use
in infants less than one month of age have not been established
Adverse Reactions: Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2.5 percent of patients
and include diarrhea (1 in 70)
Symptoms of pseudomembranous colitis may appear either during
or after antibiotic treatment Nausea and vomiting have been reported
rarely
Hypersensitivity reactions have been reported in about 1 5 percent
of patients and include morbilliform eruptions (1 in 100) Pruritus,
urticaria, and positive Coombs' tests each occur in less than 1 in 200
patients. Cases of serum-sickness-like reactions (erythema
multiforme or the above skin manifestations accompanied by
arthritis/arthralgia and, frequently, fever) have been reported These
reactions are apparently due to hypersensitivity and have usually
occurred during or following a second course of therapy with Ceclor
Such reactions have been reported more frequently in children than in
adults Signs and symptoms usually occur a few*days after initiation
of therapy and subside within a few days after cessation of therapy
No serious sequelae have been reported Antihistamines and
corticosteroids appear to enhance resolution of the syndrome
Cases of anaphylaxis have been reported, half of which have
occurred in patients with a history of penicillin allergy.
Other effects considered related to therapy included eosinophilia
(1 in 50 patients) and genital pruritus or vaginitis (less than 1 in 100
patients).
Causal Relationship Uncertain— Transitory abnormalities in clinical
laboratory test results have been reported Although they were of
uncertain etiology, they are listed below to serve as alerting
information lor the physician
Hepatic— Slight elevations of SGOT, SGPT, or alkaline phosphatase
values (1 in 40)
Hematopoietic— Transient fluctuations in leukocyte count,
predominantly lymphocytosis occurring in infants and young children
(1 in 40)
Renal— Slight elevations in BUN or serum creatinine (less than 1 in
500) or abnormal urinalysis (less than 1 in 200)
I061782R)
* Many authorities attribute acute infectious exacerbation of chronic
bronchitis to either S pneumoniae or H. influenzae •
Note Ceclor is contraindicated in patients with known allergy to the
cephalosporins and should be given cautiously to penicillin-allergic
patients
Penicillin is the usual drug of choice in the treatment and
prevention ol streptococcal infections, including the prophylaxis of
rheumatic fever See prescribing information
References
1 Antimicrob Agents Chemother , 8 91 , 1975
2 Antimicrob Agents Chemother , 1 1 470, 1977
3 Antimicrob Agents Chemother , 13 584, 1978
4 Antimicrob Agents Chemother , 12 490, 1977
5 Current Chemotherapy (edited by W Siegenthaler and R Luthy),
II 880 Washington, 0 C.; American Society for Microbiology,
1978
6 Antimicrob Agents Chemother , 13 861, 1978
7 Data on file, Eli Lilly and Company
8 Principles and Practice ot Infectious Diseases (edited by G L
Mandell, R G Douglas, Jr , and J.E Bennett), p 487 New York
John Wiley & Sons, 1979.
© 1982, ELI LILLY AND COMPANY
Additional information available to
the profession on request from
Eli Lilly and Company,
Indianapolis. Indiana 46285
Eli Lilly Industries. Inc
Carolina, Puerto Rico 00630
>L. 81— NUMBER 4— APRIL 1984
309
Working together
It can make the difference^
There are certain times when working together helps
you accomplish what you couldn’t alone.
In the medical profession, it can save lives.
The American Medical Association and your state
and county medical societies believe in the value of
teamwork — and the necessity of it, in the face of an
increasingly complex professional environment.
We also beiieve that medical societies have certain
tasks that the individual physician couldn’t possibly
assume — and shouldn’t have to.
For example, to keep government regulations from
interfering with your practice, we effectively repre-
sent your interests at local and national levels.
And to keep you up to date on the latest medical
advances, we publish JAMA, specialty, state, and
county journals.
Why do we believe that teamwork can make such
a difference?
Because the very existence of the AMA is solid
proof that when physicians work together, they can
make their own decisions, .protect their own free-
doms, and control their own destinies.
And when you have a goal like that, working
together makes all the difference in the world.
Join Your
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310
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Rehabilitation of Cognitive Function
in Brain-Damaged Persons
Irwin W. Pollack, m.d., Herbert Kohn, ph.d., Michael H. Miller, ph.d., piscataway*
There has been a growing optimism about the possibility of
improving impaired cognitive function in patients who have
suffered serious brain injury. Therapeutic activities directed at
redeveloping the patient's ability to devise new problem-solving
strategies hold the greatest promise.
Recent technological develop-
ments in medicine have enabled
physicians to keep patients alive
who once would have died; yet, this progress is not
without a price because many of those who survive are
left with permanent disabilities. A significant portion
of this group consists of adolescents and young adults
who have suffered brain injuries as a result of auto-
mobile, motorcycle, or sports accidents.1
The magnitude of the problem is reflected in a report
on the findings of the National Head and Spinal Cord
Injury Survey, from which it is estimated that each
year between 30,000 and 50,000 people with serious
head injuries are left with physical and intellectual
impairments so severe that they are unable to resume
their usual activities.1 From these statistics, it can be
estimated that over 1,700 individuals in New Jersey
are disabled as a result of a brain injury each year.
Rehabilitation activities for many of these impaired
young people are terminated when they are able to
walk, communicate, and carry out the ordinary ac-
tivities of daily living. However, the restoration of these
skills always does not enable the patient to. resume a
productive life because the residual cognitive deficits,
which are a product of every serious brain injury, have
been left untreated. Until quite recently, impairments
in cognitive function were considered to be un-
modifiable, a point of view which stemmed from the
fact that brain cells once destroyed never are replaced.
Fortunately, the increase in survival rate after brain
injuiy has inspired a reappraisal of the possibilities for
restoring effective cognitive function. Over the past
two decades, enormous strides have been made in the
field of brain physiology and behavioral neurology. Re-
training techniques that first were developed to assist
stroke patients suffering from memory and language
problems have been modified and now are being used
in the rehabilitation of individuals who have suffered
other types of brain damage, often as a consequence
of closed head injuries.3
BEHAVIORAL EFFECTS OF CLOSED HEAD
INJURIES
When a person strikes his head with great force, the
ensuing damage to the brain is not limited to the point
of impact. Remote parts of the brain are involved as
well. Closed head injuries are the product of several
forces in addition to the impact itself; especially signifi-
cant is the sudden violent deceleration and rotation
which leads to twisting of the brain on the brain stem.
This causes a shearing and tearing of nerve fibers in
the ascending reticular tracts of the brain stem which,
with the accompanying edema, is responsible first for
coma and later in the recovery process for a subnormal
level of alertness.4
*From the Department of Psychiatry, UMDNJ-Rutgers Medi
cal School. Correspondence may be addressed to Dr. Pollack,
UMDNJ-Rutgers Medical School, Piscataway, NJ 08854.
31 1
VOL. 81— NUMBER 4— APRIL 1984
Damage to the cerebral cortex itself usually is ex-
pressed behaviorally in two ways. The first type of defi-
cit behaviors is related to specific functions of the
particular areas of the brain that have been injured.
These localized effects of brain injury include paralysis,
visual field defects, difficulty in understanding and
expressing oneself in spoken and written language,
and problems in organizing personal and external
space.
The second type of deficit cannot be attributed to a
disruption of the function of a specific brain area, but
appears to be related to the generalized disruptive ef-
fect which any major injury has on brain function. One
of the behavioral consequences of this nonspecific im-
pairment of function is a decrease in the ability to
focus and sustain attention to a task; hence, many
individuals who have suffered a closed head injury are
distracted easily. In addition, both cognitive and motor
activities markedly are slowed and many patients
exhibit a reduced ability to process information at nor-
mal rates. Because the brain-injured patient frequently
receives more information than he can handle easily,
he tends to respond to the most obvious aspect of the
situation while disregarding the context in which it is
embedded. Another frequent consequence of serious
brain injury is a loss of initiative and a reduction in
social competence. To family members, this often is the
most disrupting of all the patient’s problems. Many are
described as less mature, intrusive, childlike, and gen-
erally “out of step.” As a result, old friends who may
have demonstrated a sympathetic interest during the
patient’s “sick phase” gradually drift away. Loneliness
often is the most tragic aftermath of a serious brain
injury.5
COGNITIVE REHABILITATION: THE CONCEPT
Cognitive rehabilitation programs start where the
traditional therapies which concentrate primarily on
improving physical and language abilities leave off.
Retraining efforts are aimed at improving the impaired
cognitive functions by using techniques which take
advantage of the gains already made in these areas
and, when possible, by circumventing the remaining
deficits. Emphasis is placed upon the development of
new problem solving strategies rather than on rebuild-
ing lost skills because the ability to transfer skills from
one situation to another greatly is reduced after brain
injury. For example, a patient might become quite
proficient in duplicating complex geometric patterns
using groups of colored blocks but this skill does not
enhance the individual’s ability to manipulate other
objects in space nor does it assist him to find his way
home from the hospital. On the other hand, by their
very nature, strategies can serve the individual in a
number of situations without requiring him to rear-
range or to reorganize his approach to solving a prob-
lem.
Retraining exercises are designed to simulate “real
world” situations. They provide the patient with a
structure within which he can work to improve his
ability to pay attention, to remember, and to organize
and integrate information of various kinds. In each
exercise, the patient is confronted with a task to be
carried out and is encouraged to master it. When he
succeeds, he is rewarded with praise and then he
proceeds to the next task. If he fails to respond effec- i
tively, he is given sufficient cues by the therapist so
that, with the additional information, he is able to
complete the task. When the patient is able to work
through a retraining exercise consistently without as-
sistance from the therapist, he is considered to have
developed a usable strategy and a new, more complex
set of tasks is presented to him.
Since each person has a unique learning style, it is
impossible to know beforehand which particular prob-
lem-solving strategy will be best for a given individual.
Therefore, each person is given the opportunity to
work on a predetermined set of training exercises
under the close observation of the therapist. Gradually,
out of this shared experience, the most effective
strategy for carrying out each task evolves. The ex-
ercises are presented in a step-wise progression mov-
ing from simple to more complex. Each one is designed
to make the patient aware of his cognitive deficits
while at the same time providing him with a vehicle
through which he can develop a more effective prob-
lem-solving strategy. The patient always is an active
participant in the process. The therapist, in turn, is
responsible for providing the patient with immediate
and specific feedback.67
PATIENT SELECTION: WHO CAN PROFIT?
Each brain-injured patient’s potential for improved
cognitive function depends on the ability to build upon
his preserved areas of competence. Therefore, the
proper assessment of the patient's postinjuiy cognitive
function requires that the rehabilitation staff obtain
a detailed history of his preinjury/experience with
special emphasis on the level of previous school and
job performance.
Our experience has shown that in order to benefit
from a cognitive retraining program such as the one
described above, a patient should have a minimum
post injury I.Q. of 80 and should be able to com-
municate in simple spoken and written language.
Furthermore, he should be free of any emotional dis-
order which would interfere with his full participation
in the rehabilitation activities. Ideally, the patient
should recognize that he has more difficulty learning
than he had before his injury but he need not be aware
of the exact nature of his deficits. In fact, the thrust
of the rehabilitation program is directed toward help-
ing the patient to recognize both his residual deficits
and his remaining assets. In most cases, the patient’s
physical disabilities are not a limiting factor in the
cognitive retraining process.
OUTCOME ASSESSMENT
The problems which are encountered in evaluating
the results of cognitive retraining are signficant. They
are rooted, in part, in the absence of documentation
relating to preinjury events and behaviors which could
providg information pertinent to an individual’s poten-
tial for rehabilitation. Unfortunately, valid preinjury
test results rarely are available. School group in-
telligence and achievement tests are of little value in
assessing an individual’s abilities and potential unless
they are repeated at regular intervals over a number
of years. School grades, if they are consistent, are a
better indicator of preinjury cognitive ability than are
312
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
isolated test results.
Frequently, there is a failure to screen for such prein-
juiy conditions as alcoholism and drug abuse which
compromise cognitive efficiency. The absence of this
kind of information also limits the value of outcome
studies.8
Heterogeneity in the type and severity of the brain
damage presents yet another problem. It would be ac-
curate to say that no two individuals are injured in the
same way. Improved x-ray techniques provide some
help, but, frequently, the degree of cognitive impair-
ment experienced after a head injury is unrelated to
the extent of the visualized damage. Finally, every out-
come study must allow for the fact that most individ-
uals who have suffered a brain injury show spon-
taneous improvement in their physical condition,
language abilities, and cognitive functions. Usually, the
most significant gain occurs during the first 6 to 12
months following the injury. Although additional gains
in cognitive function have been recorded well beyond
the second postinjury year, the rate of improvement
markedly is attenuated.
Despite the difficulties inherent in evaluating
changes in cognitive function after a brain injury, the
evidence supporting the effectiveness of systematic re-
training is substanial.369
THE RUTGERS MEDICAL SCHOOL PROGRAM
The Rutgers Medical School Cognitive Rehabili-
tation Program is divided into four retraining units.
The first consists of a series of exercises designed to
improve the patient’s ability to focus and to sustain
attention. Examples of these exercises include one in
which the patient is required to play a video game
while he converses with the therapist, answers specific
questions, or works on simple arithmetic problems.
Another requires the patient to observe a colored light
as it moves around the circumference of the circle and
to signal the therapist when it arrives at pre-
determined points along the pathway.
The second training unit is designed to help the
patient to increase the amount of information he is
able to process in a given time period. Training ex-
ercises in this unit provide the individual with practice
in sequencing, grouping, categorizing, and summariz-
ing information. For example, the patient is given a
newspaper article to read and he is instructed to write
out the most significant information contained in it.
From this material he develops a summary and finally
constructs a representative headline.
The third retraining unit consists of exercises de-
signed to help the patient to develop strategies that he
can use for solving problems. In a typical exercise, the
therapist provides background information from
which the patient is required to develop a logical se-
quence of questions. In order to be acceptable, a ques-
tion must be based only on the available information
and the answer must add relevant new data to the
information base. The new information, thus obtained,
is integrated with the previously acquired and, if
necessary, the whole is reorganized. From this new
data base, the next appropriate question is developed.
When the patient believes that he understands the
nature of the problem, he is asked to propose a solu-
tion, preferably one which involves a compromise ac-
ceptable to both parties.
The fourth training unit employs exercises which
provide the patient with an opportunity to enhance his
ability to communicate effectively. Each exercise gives
the patient an opportunity to express himself in words
and in actions. As a participant observer, he learns to
hear and to consider another person’s viewpoint. Each
exercise is videotaped and is played back to the group
immediately so that it can be reviewed while the im-
pressions are still vivid.
In addition to the formal cognitive retraining ex-
ercises, patients participate in carefully chosen rec-
reational activities and in social functions which they
help plan. The need for the patient to think through
each activity is emphasized in all segments of the re-
habilitation program.
There are enormous stresses on the family of a
brain-injured person. Usual family interrelationships
are disrupted. In order to be available to care for the
patient, parents are required to modify their lives and
plans for the future. Frequently, younger siblings are
recruited to assume part of the caretaking
responsibilities for an older cognitive-impaired
brother or sister who continues to demand the rights
of seniority. For these reasons, tension between the
patient and siblings often is intense. In order to assist
the family to maintain a reasonable balance, routine
counseling sessions are provided by the members of
the rehabilitation staff.
The staff of the Rutgers Medical School Program has
endeavored to minimize the influence of many of the
factors which in the past have complicated the evalu-
ation of program effectiveness. For example, when
criteria enumerated in the Glasgow Coma Scale are
applied, all but 2 of the 13 patients who were accepted
for retraining had experienced a period of coma ex-
ceeding ten days. Coma which exceeds one week in
duration generally is recognized as indicating that a
severe brain injury has occurred and that the prog-
nosis for spontaneous recovery of effective cognitive
functioning is poor.10 Further, 1 1 of the 13 patients
admitted to the program had experienced brain injury
at least 12 months before the onset of their rehabili-
tation activity, so that it can be assumed that the
spontaneous recovery of function contributes only a
small amount to the observed cognitive gains.
Finally, the cognitive retraining exercises do not em-
ploy materials taken from the tests which are used to
evaluate patient progress. Because of this, the effect of
practice on the test results is reduced. However, be-
cause each patient is retested at regular intervals,
there is no way to eliminate all practice effects.
Although most of the patients in the Rutgers Medi-
cal School Program still are actively involved in their
retraining activities, retesting after a period of 13
weeks (39 therapeutic sessions) showed a pattern of
improvement which was remarkably uniform. Certain
subtests of the Halstead-Reitan Battery, one of the two
test batteries which regularly are used to evaluate pa-
tient progress, showed significant positive changes.
These subtests (the Trail Making Test, the Category
Test, and the Tactual Performance Test) evaluate the
patient’s ability to process nonverbal information as
well as the ability to recognize inherent relationships
among pieces of information within categories. An in-
VOL. 81— NUMBER 4 — APRIL 1984
313
dividual’s performance on these subtests also reflects
the ability to be flexible in the approach to problem
solving. The ability to recognize the relationship be-
tween discreet pieces of information is necessaiy if
learning is to take place. In addition to showing greater
competence on these Halstead- Rei tan subtests, most
of the patients also improved their performance on
certain subtests of the Wechsler Adult Intelligence
Scales, the other test battery used routinely to evaluate
patient progress. This battery, which is subdivided
into a group of verbal tests and a group of performance
tests, has been used more frequently than any other
to evaluate the changes in cognitive function which
occur following a brain injury. Improvement early in
the rehabilitation process most commonly is seen on
performance tasks: however, these results must be in-
terpreted cautiously since several subtests in the Per-
formance Scale are among those most subject to prac-
tice effects. After 13 weeks in a retraining program, our
patients showed gains in performance I.Q. ranging
from 0 to 20 points with an average gain of 8 I.Q.
points.
Although better test performance is an important
indicator of improved cognitive function, test results
alone, no matter how reliable, mean little if the patient
is unable to return to school, cannot hold a job, and
has no social life. Some of the earliest indicators of
improving cognitive ability are reflected in changes in
the patient’s attitude rather than in improved intellec-
tual function. Family members frequently refer to the
patient’s growing interest in the affairs of the family.
A slowly developing curiosity about events which are
occurring outside of the home also have been reported.
The patient also may show an increase in initiative
that leads him to assert himself more. This new force-
fulness can bring him into conflict with other family
members. As the therapeutic process continues, pa-
tients often seem less self-involved, less concrete, and
more appropriate in their relationships to others. Dur-
ing the final stages of the rehabilitation process indi-
viduals seem better able to recognize both their
cognitive strengths and remaining deficits.
CASE REPORT 1
A 21 -year-old white male university student, was in-
jured in a motor vehicle accident in March 1980. He
was thrown from the car striking the left side of his
head. Examination at the time of admission to the
hospital revealed a young man with a markedly re-
duced level of consciousness who had a right hemi-
plegia a fracture of the left wrist, and multiple lacer-
ations. A computed tomographic brain scan showed a
left parietal lobe intracerebral hemorrhage. On the
tenth postaccident day, the patient began to respond
regularly to verbal stimulation. Over the next two
weeks he became progressively more alert and respon-
sive although he remained confused and had poor
short-term memory.
Seventeen days after the accident, the patient was
transferred to a rehabilitation hospital for continued
care where he remained for approximately five months.
He was discharged from the hospital to his parent’s
home in August 1980. Although he had made signifi-
cant gains, some physical deficits remained including
a residual right-sided weakness and reduced tactile
314
discrimination ability. His attention span and short-
term memoiy had improved signficantly, but he still
had difficulty organizing and integrating information
and in separating relevant from irrelevant data In ad-
dition, both motor activity and cognitive processing
were significantly slowed. He was able to behave ap-
propriately in social situations but he still showed
signs of immaturity.
During the following year he lived at home and re-
ceived outpatient physical therapy and speech therapy.
In September 1981, the patient returned to the univer-
sity against the advice of his parents who felt he was
not yet ready. By the end of the fall semester, he was
failing in almost every course. He returned to the uni-
versity for the second semester in January 1982, but
after a brief period he saw the impossibility of his
situation and elected to return home. It was at this
point that he applied for admission to the Rutgers
Medical School Cognitive Rehabilitation Program.
In February 1982, a preadmission neuropsy-
chological examination showed that the patient had
significant residual problems in organizing infor-
mation and in carrying out more than one mental
operation at the same time. When he was confronted
with more information than he could easily manage,
he reverted to a literal interpretation of the material.
In addition, he showed a reduced sensitivity in social
situations and had a limited ability to monitor cues ;
given by others. On the Wechsler Adult Intelligence
Scale, he had a full scale I.Q. of 106, a verbal I.Q. of 1 14,
and a performance I.Q. of 94. Although no preinjury
intelligence test scores were available for comparison,
the patient’s college admission test scores and high
school grades placed him in the 98th percentile of
college-bound high-school seniors. Taken together,
this information strongly suggests that he had a prein-
jury I.Q. in the range of 125 to 135.
The patient began his cognitive rehabilitation pro-
gram early in March 1982. He regularly attended three
two-and-one-half hour therapy sessions each week for
a period of 36 weeks. In the fall of 1982, he registered
for two college level courses which he successfully com-
pleted in January 1983. The complete neuropsy-
chological battery was readministered in December
1982 at the end of 36 weeks in the program. The
results showed improvement in tactile discrimination
and information processing. On the Wechsler Adult
Intelligence Scale, his posttherapy verbal I.Q. was 127,
his performance I.Q. was 108, and his full scale I.Q. was
120. Reports from the patient’s family indicated that
though there was some improvement in his ability to
handle social situations, he was still somewhat im-
mature and had made few new friends. Much of his
time was spent alone studying for his courses.
CASE REPORT 2
The patient, a 23-year-old white female, was injured
in a motor vehicle accident in March 1979. She was
thrown from the car and struck the left side of her
head. Neurological examination revealed evidence of a
significant contrecoup injury to the right parietal-oc-
cipital area. At the time of her admission to the hospi-
tal she was unresponsive to all stimulation. Over the
following two weeks, her coma lightened but she con-
tinued to show fluctuating levels of alertness. After
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
i
three weeks, the patient was transferred to a rehabili-
tation hospital where she remained until July 1979.
An electroencephalogram in May 1979 demonstrated
a bilateral spike and slow wave pattern most promi-
nent over the right frontal area. As a precautionary
measure, she was placed on phenobarbitol 30 mg b.i.d.
Although the patient made remarkable progress
while in the rehabilitation hospital, she was left with
some residual deficits. There was a minimal left-sided
weakness and a persisting left visual field defect. More
troubling were the remaining cognitive deficits which
included reduced auditoiy and visual memory, slow
information processing, and word finding difficulties.
She also had a limited ability to carry out two mental
activities simultaneously, e.g. listening and writing
notes. She showed little initiative and her level of social
competence was reduced markedly. All motor and
cognitive activities were performed quite slowly.
By October 1979, the patient was able to return to
the part-time clerical job she had held prior to her
injury. In addition, she reenrolled as a part-time stu-
dent in the school of business which she had been
attending at the time of her accident. Because of her
continuing cognitive problems, she was unable to
manage her secretarial courses and transferred to a
less demanding clerical curriculum which she man-
aged to complete despite the fact that she was severely
hampered by her slow response rates. At the time of
her admission to the Rutgers Medical School Cognitive
Rehabilitation Program in December 1981, she still
was working part-time at her clerical job. In an evalu-
ation of the patient’s job performance, a supervisor
noted that she was a pleasant and dedicated worker
who was functioning adequately, if not entirely com-
petently. During the preadmission interview, the pa-
tient stated that she was seeking help because she
could not remember how to carry out certain job
procedures. Her parents expressed concern because
she had lost many of her old friends and had shown
little initiative in making new ones. In addition, they
stated that she seemed uninterested in many of the
activities that had occupied her profitably prior to her
injury.
A preadmission neuropsychological evaluation in
December 1981 showed significant residual impair-
ments in cognitive function. The patient's deficits in-
cluded a reduced ability to focus and sustain attention.
The resultant heightened distractability caused her to
have difficulties controlling the inflow of information.
Even after she had identified relevant pieces of infor-
mation, she was quite slow in organizing them. In
addition, she appeared to be socially immature and
showed little spontaneity. On the Wechsler Adult In-
telligence Scale, she obtained a verbal I.Q. of 92, a
performance I.Q. of 91, and a full scale I.Q. of 91.
Although the patient had never been an excellent stu-
dent, her average high school grades had been in the
B to C range; these I.Q. test results clearly represented
a drop from her preinjury level of intelligence.
The patient completed her cognitive rehabilitation
program in June 1982 approximately seven months
after her admission. The complete neuropsychological
battery was administered again and the results show-
ed improvement both in verbal and performance areas
of function. The verbal I.Q. was 99, her performance
I.Q. 107, and her full scale I.Q. was 102. The patient
was able to process greater amounts of information
effectively and showed significant improvement in her
ability to manage abstract concepts. In his latest re-
port, her supervisor at work had given her a competent
performance evaluation and she had been offered the
opportunity to work additional hours. Her parents re-
ported that she was more organized in her activities
at home and that she was becoming more adept in
social situations. Further evidence of her progress was
the fact that, with the encouragement of her family,
she successfully pursued a course of study in the local
center for adult education. As far as her parents are
concerned, the patient’s major remaining problem is
her continuing lack of initiative.
COMMENT AND CONCLUSION
These cases effectively show that it is possible to
improve cognitive function through retraining ac-
tivities carried on over an extended time period. Both
of these patients not only improved their test per-
formance, but also were able to return to their prein-
juiy occupations. Both have made slower progress in
reestablishing peer relationships, a fact which has
been noted by others who work with cognitively im-
paired individuals.10 Apparently, these patients lack
the initiative to use their leisure time effectively.
Long-term followup studies have demonstrated that
the patient’s social isolation and reduced participation
in leisure activities persist even after he has recovered
sufficiently to return to a job. Many of the patients who
were interviewed reported that they were very lonely.
These findings emphasize the fact that a cognitive
rehabilitation program cannot be truly effective unless
it successfully assists its clients to reestablish a
satisfying lifestyle.
Jannett urges us to remember that “the tremendous
efforts expended on extensive treatment in the early
weeks after injury often are largely wasted by the fail-
ure to provide the means whereby the full potential for
recovery can be achieved during the later stages.”11
REFERENCES
1. Kalsbeck WD, et al.: The national head and spinal cord
injury survey: Major findings. J. Neurosurg 53:19-31, 1980.
2. Diller L: Psychomotor and vocational rehabilitation, in
Benton AL (ed): Behavioral Change in Cerebrovascular Dis-
ease. New York, NY, Harper and Row, 1970, pp. 81-105.
3. Lezak MD: Neuropsychological Assessment 2nd Ed.
New York, NY, Oxford University Press, 1983, pp. 167-169.
4. Weddell R, et al.: Social adjustment after rehabilitation:
A two-year followup of patients with severe head injury. Psy-
chol Med 10:257-263, 1980.
5. Ben-Yishay Y: Working approaches to reme-
diation of cognitive deficits in brain damage. IRM Behavior
Science, Rehabilitation Monograph: 61, 1980.
6. Ben-Yishay Y: Working approaches to remediation of
cognitive deficits in brain damage. IRM Behavior Science.
Rehabilitation Monograph: 62, 1981.
7. Levin H, et al.: Neurobehavioral Consequences of Closed
Head Injuries. New York, NY, Oxford University Press, 1981,
pp. 208-215.
8. Gianutsos R, Gianutsos J: Rehabilitating the verbal re-
call of brain-injured patients by mnemonic training: Clin
Neuropsy 1:117-135, 1979.
9. Jennett B, Plum F: Outcome after severe brain damage:
A practical scale. Lancet I: 480-483, 1975.
10. Oddv M, et al.: Subjective impairment and social re-
covery after closed head injury. J Neurolol Neurosurg Psy-
chiatnj 41:61 1-616, 1978.
11. Jennett B: Who cares for head injuries? Br Med J
3:267-270, 1975.
VOL. 81— NUMBER 4— APRIL 1984
315
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Case Report:
Tuberculous Abscess of the Spleen
William E. Farrer, m.d., and Suresh Ramamurti, m.d., Elizabeth*
A male with subacute febrile systemic illness was found to have
a solitary abscess of the spleen caused by Mycobacterium
tuberculosis. Splenic abscess is a relatively rare condition and
causes difficulty in diagnosis . Localized tuberculosis of the spleen
is rarer and diagnosis often is delayed.
Isolated splenic abscess is un-
common. A recent review from
Cleveland Metropolitan Hospi-
tals revealed only 10 cases in an 1 1-year period (0.1 1
percent of admissions and 0.22 percent of autopsies)1
and 14 cases were seen at the University of Louisville
Associated Hospitals over an 18-year period.2 The high
reported mortality rate, even in the antibiotic era,2 and
the frequency of diagnosis only at postmortem examin-
ation stress the difficulty in diagnosis and treatment
of this condition. Although a wide range of organisms
have been reported to cause splenic abscesses,1
Mycobacterium tuberculosis is an extremely rare
etiologic agent of isolated splenic abscess, especially in
recent years. Our report concerns a patient who was
successfully treated for tuberculous abscess of the
spleen.
CASE REPORT
A 48-year-old black male was admitted to St. Eliza-
beth Hospital on November 2, 1981, with a several
month history of fever, chills, night sweats, headaches,
and anorexia. He also complained of pleuritic left chest
and upper arm pain, mild left upper quadrant pain,
and early satiety. He had no significant recent travel,
but while in the Army from 1952 to 1963 he traveled
worldwide. He had pneumonia in 1952 but had no
history of tuberculous infection or exposure. There
was heavy alcohol intake until three years prior to
admission and a 35 pack-year smoking history.
Initial physical examination revealed no fever or
other abnormalities.
Laboratory data were unremarkable, except for
sedimentation rate of 87 and alkaline phosphatase of
163 U/L (normal to 115 U/L). Hemoglobin was 13
gm/DL and white count 8,000. SCOT was 35 U/L (nor-
mal to 40 U/L). Bone, liver-spleen, and gallium scans
and upper gastrointestinal series with small bowel fol-
low-through were interpreted as normal, as was the
chest x-ray. Multiple blood cultures were negative. T3
and T4 were normal. 5 TU PPD produced 20 mm of
induration at 48 hours. The CT scan of the abdomen
(Figure 1) showed a large septated cold area in an
enlarged spleen. In retrospect the liver-spleen and gal-
lium scans also were abnormal.
The patient underwent splenectomy on November
16, 1981, and the spleen was found to be three times
normal size, adherent to the diaphragm and to the
retroperitoneal surface, with a large abscess. There
also were enlarged retroperitoneal lymph nodes; the
liver appeared normal. The spleen weighed 720 gm and
consisted mostly of necrotic material. Pathology
showed stellate suppurative abscesses and granu-
lomatous inflammation with Langerhans’ cells and
*From the Division of Infectious Diseases, Department of
Medicine, St. Elizabeth Hospital. Correspondence may be ad-
dressed to Dr. Farrer, St. Elizabeth Hospital, 225 Williamson
Street, Elizabeth, NJ 07207.
VOL. 81— NUMBER 4— APRIL 1984
317
Figure 1— Computerized tomography of abdomen showing
septated abscesses in spleen (arrowheads). Lliver; S:spleen.
Figure 2 — Section of splenic abscess showing granuloma for-
mation. Arrow denotes Langerhans' giant cell. Hematoxylin-
eosin; magnification 400X.
other giant cells (Figure 2). A liver biopsy revealed
nonspecific triaditis but no granulomata; a lymph
node had chronic lymphadenitis with focally necrotic
granulomata. Acidfast bacillus (AFB) and fungal stains
were negative.
Postoperatively, the patient had a transient fever to
101.5° but defervesced without antibiotic treatment.
Routine cultures were negative and the patient was
discharged on November 29, 1981, on no treatment.
He felt well until one month later when he had
recrudescence of fever, chills, and sweats, with increas-
ing abdominal girth but no abdominal pain. He was
empirically treated with ampicillin, but showed no
response and was readmitted on January 7, 1982. At
this time, physical examination revealed an ill looking
black male in no acute distress. Temperature was
101.5. Abdomen had evidence of ascites, but no re-
bound or masses. White blood count was 1 1,000 with
49 polys, 12 bands, 29 lymphs; hemoglobin was 14.7
gm/DL. Chest x-ray was negative. Alkaline phos-
phatase was 126 U/L; SGOT, 66 U/L. An abdominal
paracentesis yielded 500 ml of amber-colored fluid. No
cell counts or chemistries were performed, but the
gram and AFB stains were negative as were routine
cultures.
At this point, the cultures of the splenic abscess on
Lowenstein-Jensen media were noted to be positive for
AFB. The patient was started on isoniazid 300 mg/day,
rifampin 600 mg/day, and ethambutol 15 mg/kg/day,
and defervesced within 5 days. He has remained well
with an increasing sense of well-being, weight gain,
and resolution of the ascites. The organism was iden-
tified by the New Jersey State Mycobacteriology Lab-
oratories as Mycobacterium tuberculosis sensitive to
isoniazid, rifampin, and ethambutol.
DISCUSSION
The difficulty in establishing the diagnosis of splenic
abscess and the further delay in recognizing the tu-
berculous nature of the infection are characteristic of
these conditions. Clinical clues to splenic abscess may
be subtle. Fever usually is present, but often is inter-
mittent. Abdominal pain may be variable and com-
plaints of left-sided chest pain or arm pain may divert
attention from the abdomen.
X-rays of the abdomen and barium contrast studies
are helpful if they demonstrate a soft tissue mass,
extragastric left upper quadrant gas, or displacement
of stomach or splenic flexure. They may be non-
diagnostic, however. Chest x-ray may show elevated left
hemidiaphragm and/or left pleural effusion, but this
is nonspecific.2
Radionuclide studies have an increased diagnostic
yield for splenic abscess but still have difficulties,
"m Technetium scans often will show a lesion, but false
negative scans have been reported.2 4 Gallium scan can
be falsely negative due to masking by surrounding
nonnal tissue3 or nonspecific due to generalized in-
creased uptake in the setting of sepsis.4 67Gallium
scanning has been proposed as a simple and reliable
screening tool for extrapulmonary tuberculosis.5 In our
patient, however, the gallium scan showed very subtle
changes noted only in retrospect.
Ultrasonography67 and computed tomographic (CT)
scanning4 are more sensitive and specific and can give
anatomic detail. These techniques have not only in-
creased diagnostic accuracy in splenic abscess but
have even permitted percutaneous drainage.
The most common organisms isolated from splenic
abscesses are Staphylococcus aureus, various strep-
tococci, gram-negative bacilli, and Mycobacterium tu-
berculosis. Other organisms occasionally are re-
ported.1
In the prechemotherapy era tuberculous involve-
ment of the spleen was not so rare. Early authors dif-
ferentiated primaiy tuberculosis of the spleen, in
which the disease process is localized to the spleen,
from secondary tuberculosis.8 10 The latter is as-
sociated with active tuberculosis in other organs, such
as peritonitis," or disseminated tuberculosis. They
pointed out that while the spleen is not the portal of
entry or even the first site of active tuberculosis in
primaiy tuberculosis of the spleen, the spleen can act
as the focus for dissemination of the disease while the
original focus may heal entirely. Wintemitz reported a
case and reviewed 50 previous reports of primary tu-
berculosis of the spleen.8 He noted that the disease
could be chronic and many patients did not have
anemia or leukocytosis; only a small percentage of
cases had definite abscess formation. In 1933,
Shands10 reported 3 cases of primaiy splenic tubercu-
318
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
losis, 1 case with abscess; Rumold and Orr 9 reported
a case of splenic tuberculous abscess. Very few cases
of primaiy splenic tuberculosis and even fewer of
solitaiy tuberculous abscess of the spleen have been
reported since the introduction of effective
chemotherapy and these not always have been
documented properly.12 15
This patient seems to have had primary tuberculosis
of the spleen. His chest x-ray and CT of the chest
showed no evidence of active or past tuberculosis. At
laparotomy, there was no hepatic or generalized
peritoneal involvement. Postoperative development of
ascites probably represented tuberculous peritonitis
from local seeding at the time of surgery with rapid
therapeutic response to appropriate antituberculous
medication. In retrospect, the positive PPD with granu-
lomata in the resected spleen and draining lymph
nodes, albeit atypical, should have prompted earlier
therapy.
The origin of splenic abscess in our patient is un-
known. The spleen may have been seeded
hematogenously at some remote time and disease reac-
tivated after other evidence of disease had resolved.
Lack of apparent intrathoracic involvement makes
direct extension through the diaphragm unlikely and
there was no other intra-abdominal involvement noted
at the time of surgery.
As tuberculosis becomes increasingly uncommon in
our society, the chance of missing a diagnosis of ex-
trapulmonary tuberculosis increases. Long delays in
diagnosis are common in such conditions as tubercu-
lous meningitis,16 peritonitis,11 17 enteritis,17 18 and
spondylitis.19 Tuberculosis should be considered as a
cause of splenic abscess. Left upper quadrant symp-
tom and signs and the presence of a positive PPD
should prompt investigation.
REFERENCES
1. Chulay JD, Lankerani MR Splenic abscess: Report of 10
cases and review of the literature. Am J Med 161: 513-522,
1976.
2. Chun CH, Raff MJ, Contreras L, et al.: Splenic abscess.
Medicine 59: 50-65, 1980.
3. Simson JNL: Solitary abscess of the spleen. Br J Surg
67: 106-110, 1980.
4. Baruch J, Levy Y, Brook JG, Kleinhaus U, et al.: Splenic
abscess diagnosed with the aid of abdominal CT: Report of
two eases. Br J Surg 68: 37-138, 1981.
5. Sarkar SJ, Ravikrishnan KP, Woodbury DH, et al.: Gal-
lium— 67 citrate scanning — a new adjuct in the detection and
followup of extrapulmonary tuberculosis. J Nucl Med 20:
833-836, 1979.
6. Pawar S, Kay CJ, Gonzalez R et al.: Sonography of
splenic abscess. AJR 138: 259-262, 1982.
7. Ralls PW, Quinn MF, Colleti P, et al.: Sonography of
pyogenic splenic abscess. AJR 138: 523-525, 1982.
8. Wintemitz MC: Tuberculosis of the spleen. Arch Intern
Med 9: 680-697, 1912.
9. Rumold MJ, Orr JG: Tuberculosis abscess of the spleen.
Ann Surg 98: 474-477, 1933.
10. Shands MR Chronic primaiy tuberculosis of the
spleen. Am J Surg 20: 707-721, 1933.
11. Dineen P, Homan WP, Grafe WR Tuberculous peri-
tonitis: 43 years experience in diagnosis and treatment. Ann
Surg 184: 717-722, 1976.
12. McGowan WB: Primary tuberculosis of the spleen. Cent
AJr J Med 11: 39-40, 1965.
13. Fung WP, Siew CO, Lee YS: Splenic tuberculosis pres-
enting as pyrexia of unknown origin. Med J Austr 1 : 446-448,
1973.
14. Paris J, Ribet M, L'Hermaine C, et al.: Absces froids
tuberculeux de la rate au cours d’une biharziose h£pato-in-
testinale Evolutive. Sem Hop Paris 52: 1870-1872, 1976.
15. Cummings Y, Cruz I, Rovi J, et al.: Primary splenic
tuberculosis in transplant candidates. JNMA 70: 167-169,
1978.
16. Swart S, Briggs RS, Millac PA Tuberculous meningitis
in Asian patients. Lancet 2: 15-16, 1981.
17. Sherman S, Rohwedder JJ, Ravikrishnan KP, et al.:
Tuberculous enteritis and peritonitis: Report of 36 general
hospital cases. Arch Intern Med 140: 506-508, 1980.
18. Tabrisky J, Linstrom RR Peters R et al.: Tuberculous
enteritis, review of a protean disease. Am J Gastroenterol 63:
49-57, 1975.
19. Marcq M, Sharma OP: Tuberculosis of the spine: A
reminder. Chest 63: 403-408, 1973.
VOL. 81— NUMBER 4— APRIL 1984
319
Case Report:
Intrauterine Testicular Torsion
Joel Rosenberg, m.d., and Milton Zimmerman, m.d., clifton*
Torsion of the testicle can occur in utero . The diagnosis is made
by physical examination in the newborn . Surgical intervention is
the treatment , although the affected testicle uniformly is
nonsalvage able. The contralateral testicle almost invariably is
normal but surgical repair to prevent torsion is recommended.
Torsion of the testicle can occur
in utero and despite the relative
paucity of ease reports, it is a
fairly common condition although the exact incidence
has not been defined.
CASE REPORT
Our patient was a full-term, 6-pound, 4-ounce male,
Apgar 9, born to healthy parents. At birth, physical
examination revealed the left hemiscrotum to be
swollen. The testicle was enlarged, rock hard, and pur-
ple in color through the skin. Palpation of the organ
caused the baby no apparent discomfort. The mass did
not transilluminate. The contralateral testis was nor-
mal.
A technetium scan was performed, but this was dif-
ficult to interpret and deemed nondiagnostie.
When the baby was four days old, we performed
surgical exploration of the scrotum and removed the
testicle. The pathology report indicated complete in-
farction with areas of calcification (Figures 1 and 2).
1 he postoperative course was uneventful and, in
fact, the baby went home the next day. He continues
to thrive.
DISCUSSION
There are approximately 100 similar ease reports in
the literature; none of them represents a significantly
large series.1 Diagnosis is fairly simple by physical
examination alone, but technetium scanning is rec-
ommended.23 The differential diagnosis includes
tumor (yolk sac), hematocele, and other rare entities.4
The role of surgery unquestionably has been estab-
lished as all the possibilities included in the differen-
tia] diagnosis require surgical therapy. However, the
testicular salvage rate is so abysmal that surgical inter-
vention need not be on an emergency basis, but rather
elective, i.e. when the baby is stable and well
nourished.5
The literature almost uniformly describes end-stage
nonsalvageable testes at exploration. Some authors ad-
vocate leaving the infarcted testis in situ after ex-
ploration1 but this does not sit well with most sur-
geons as gangrene and infection are potential se-
quelae. The exception to the “no rush” policy would be
the rare ease where the torsion appeared to be recent
and salvage reasonably might be expected.
Most authors cite the need to repair the contralateral
normal testis and point out the occasional ease of
bilateral neonatal torsion. However, there are no case
reports where a child bom with one infarcted testicle
subsequently has gone on to have a similar episode on
the other side, asynchronously. However, extrapolating
*Dr. Rosenberg is Chief of Urology and Dr. Zimmerman is
Attending Urologist at Passaic General Hospital. Cor-
respondence maybe addressed to Dr. Rosenberg, 1 198 Clifton
Avenue, Clifton, NJ 07013.
320
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Figure 1 — Gross specimen.
from experience garnered treating teenagers, it prob-
ably is wise to repair tbe normal contralateral side.
REFERENCES
1. Guiney EJ, McGlinchey J: Torsion of the testes and the
spermatic cord in the newborn. Surg Gynecol Obstet
152:273-274. 1981.
2. Valva Jr, Caldamone AA, O'Mara R, Rabinowitz R: Nu-
clear imaging in the pediatric acute scrotum. Am J Dis Child
136:831 835. 1982.
Figure 2 — Microscopic section showing infarcted tubules.
3. Falkowski WS, Firlii CF: Testicular torsion: The role of
radioisotopic scanning. J Urol 124:886-888, 1980.
4. Kay P, Strong DW, Tank ES: Bilateral spermatic cord
torsion in the neonate. J Urol 123:293, 1980.
5. Gumming DC, Hyndman CW, Deacon JS: Intrauterine
testicular torsion: Not an emergency. Urology 14:603-604,
1979.
VOL. 81— NUMBER 4— APRIL 1984
321
Pharmacological Basis Of Therapeutics
Anticonvulsant Agents*
Herbert M. Geller, ph.d., piscataway**
The actions of many anticonvulsant agents at the cellular level
can be ascribed to a “modulatory” action to increase the effect
of the inhibitory neurotransmitter gamma amino butyric acid .
The understanding of these mechanisms may result in advances
in the pharmacotherapy of seizure disorders.
In the past several years, ad-
vances in pharmacological,
biochemical, and physiological
techniques have brought increasing insights into the
actions of anticonvulsant agents at the cellular and
molecular level. In this review, some of the recent find-
ings which indicate that many of these compounds
enhance the action of endogenous inhibitory neu-
rotransmitters in the brain will be summarized. This
enhancement of inhibition by anticonvulsants then
results in a general decrease of central nervous system
excitability. The phenomenon of selective alteration in
neurotransmission which secondarily results in alter-
ations of brain activity has been termed “neu-
romodulation”; compounds which display such ac-
tions are called “modulators.” Initial discussion will
focus on the benzodiazepines, since the remarkable
progress in our knowledge of anticonvulsant drug ac-
tion was triggered by research on this class of com-
pounds.
The first clue that benzodiazepine action might be
through modulation of neurotransmission was pres-
ented in 1967 in Germany by Schmidt et al.17 who
demonstrated that, in eats, injection of diazepam
(Valium5) potentiated “presynaptic" inhibition in the
spinal cord without affecting other “recurrent" in-
hibitory pathways. Later evidence demonstrated that
the inhibitory neurotransmitter, gamma amino
butyric acid (GABA), plays a significant role in
presynaptic inhibition in the spinal cord, whereas the !
recurrent (or postsynaptie) inhibition in the cord is
mediated through a different amino acid, glycine.
Much more evidence has accrued to suggest that
benzodiazepines potentiate the actions of GABA at
many loci throughout the central nervous system
(CNS), and that this action is observed at concentra-
tions which do not affect the activity of other neu-
rotransmitters.9
Gamma amino butyric acid elicits its action by open- j
ing channels in the nerve membrane which are per- j
meable to the negatively charged chloride ion, thus
forcing the membrane potential more negative and
decreasing the probability of activity. Additionally,
open chloride channels themselves have the effect of
reducing the actions of excitatory input, also decreas-
ing activity. It would appear that in the presence of
*This article, the second in a series, is intended to be a brief
review of recent advances in pharmacology and related
preclinical sciences which will have utility in understanding
the actions of both new and established therapeutic agents.
The reviews are not designed to consider indications for
specific drugs, incompatibilities, or dosage forms.
Authoritative information on these topics is available in
standard sources such as the AMA Drug Evaluations, 5th
edition, 1983.
**Dr. Geller is Associate Professor, Department of Pharma-
cology, UMDNJ-Rutgers Medical School. Correspondence may
be addressed to Dr. Geller, UMDNJ-Rutgers Medical School,
P.O. Box 101, Piscataway, NJ 08854.
322
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
therapeutic concentrations of benzodiazepines, the
chloride channel opens more frequently and remains
open for a longer period of time, thus potentiating the
actions of GABA.20
LIGAND BINDING SITES
The interaction between benzodiazepines and GABA
was strengthened further by the discovery in 1977 of
specific ligand binding sites for benzodiazepines in the
brain.1219 These membrane sites bind clinically rel-
evant benzodiazepines with an order of affinity that
closely approximates their phannacologie potency as
therapeutic agents.3 Moreover, the binding of these
compounds is specific: neither GABA nor any other
endogenous neurotransmitters displace benzodia-
zepines from these sites.3 Association with GABA is
reflected, however, as an ability of GABA to increase the
interaction of the benzodiazepines with their binding
sites, as well as the reciprocal ability of
benzodiazepines to increase the binding of GABA to
its receptor.1821 Thus, one can envision a macro-
molecular complex located within the nerve membrane
which consists of the GABA receptor, benzodiazepine
binding site, and chloride channel acting in concert to
regulate the excitability of individual neurons.
The utility of this concept is expanded when one
considers the actions of other agents which act to
regulate the excitability of the brain as either con-
vulsants or anticonvulsants. Bicueulline, a convulsant
alkaloid of plant origin, has been demonstrated to be
a competitive antagonist of GABA actions at the GABA
receptor, displacing GABA from its receptor and, there-
by, decreasing inhibition. Pierotoxin, another con-
vulsant agent, exerts its actions by reducing chloride
permeability: biochemical experiments have demon-
strated that pierotoxin exerts these actions by at-
taching itself in close opposition to the chloride chan-
nel, thereby reducing chloride influx. Thus, one can
expand the model we have presented to include three
separate binding sites on the complex in close associa-
tion with the chloride channel: the GABA receptor, the
benzodiazepine binding site, and the pierotoxin bind-
ing site.
The pierotoxin binding site has generated an in-
creasing amount of attention, not only for its ability
to bind pierotoxin and structurally related compounds,
but also for the ability of several other agents, both
convulsants and anticonvulsants, to bind at this site.
Thus far, both barbiturates with anticonvulsant ac-
tions and valproic acid (Depakene") have been shown
to compete with pierotoxin at this site.1622 Interest-
ingly, the agent with the highest known affinity is a
benzodiazepine compound which also is a con-
vulsant.16 The binding of these compounds also has
been shown to be paralleled by physiological responses
of the tissue. Both pentobarbital13 and valproic acid1
have the ability to potentiate the actions of GABA on
central nervous system neurons, while the physiologi-
cal actions of the convulsant compounds are quite
similar to that of pierotoxin.6 Other pharmacological
interactions at this complex include the increase in
binding of GABA23 and benzodiazepines' 1 in the pres-
ence of pentobarbital. Moreover, a separate binding
site for phenytoin has been reported to exist4; this site
also displays significant interactions with benzodia-
zepines and bicueulline.14 Whether these interactions
are pharmacologically relevant is an open question.
In parallel with the results of investigations with
opiate systems, the fact that certain brain sites bind
benzodiazepines with high affinity raises the question
of whether there exists am endogenous compound
which resembles the benzodiazepines in its actions, or
whether the binding of these agents is simply adven-
titious. The discovery of a series of compounds which
are competitive antagonists of the pharmacological ac-
tions of benzodiazepines has enabled certain studies
to proceed along these lines.10 One might suppose that,
if endogenous benzodiazepine agonists were tonically
active, then there would be a behavioral or physiologi-
cal alteration after administration of such an an-
tagonist. Again, there is a parallel with the results from
An increased understanding
of the biochemistry ,
physiology , and
pharmacology of
neurotransmission has
provided knowledge
for the pharmacotherapy
of seizure disorders.
opiate systems, where administration of naloxone
produces no behavioral changes in pharmacologically
naive patients: following the administration of
benzodiazepine antagonist compounds, no changes
are noted in behavior, nor do they produce any
changes in GABA-mediated inhibition.10 The parallel
with opiate receptor mechanisms is not strict, how-
ever, as there exists yet another class of
benzodiazepine ligands, derivatives of beta-carbolines,
which are themselves anxiety-evoking and procon-
vulsant.2 The effects of these compounds on GABA-
mediated inhibition has not yet been ascertained, but
one might predict that, in common with the other
convulsant agents, they would reduce inhibition in the
central nervous system.
THERAPEUTIC IMPLICATIONS
The major therapeutic implications of our increased
understanding of the mechanism of action of an-
ticonvulsants are yet to come. The recent revelation
that there is more than one subtype of benzodiazepine
binding site, each type with a unique biochemistry15
and anatomic localization,24 holds out the promise of
compounds which are targeted more narrowly for their
effects on either seizures, anxiety, muscle relaxation,
or sedation auid hypnosis. The use of binding assays
provides a readily available and inexpensive screen for
the identification of newer compounds with increased
potency, efficacy, or more favorable pharmacokinetic
parameters. More recently, the anticonvulsant potency
of agents which increase GABA levels by inhibiting
destruction6 or removal7 of GABA also has been dem-
onstrated.
VOL 81— NUMBER 4— APRIL 1984
323
The pharmacologic implication is that agents which
modulate the actions of neurotransmitters are worthy
of further investigation. If present-day compounds act
by increasing inhibitory neurotransmission, one
might speculate that agents which reduce excitatory
neurotransmission within the central nervous system
are candidates for anticonvulsant testing. Recent ex-
perimental evidence has supported this hypothesis as
well.5 Thus, an increased understanding of the
biochemistry, physiology, and pharmacology of neu-
rotransmission has provided fundamental knowledge
for the pharmacotherapy of seizure disorders. Whether
similar mechanisms underlie therapeutic advances in
other CNS disorders is an open question.
REFERENCES
1 . Baldino F, Jr, Geller HM: Sodium valproate enhancement
of GABA inhibition: Electrophysiological evidence for an-
ticonvulsant activity. J Pharmacol Exp Ther 217:445, 1981
2. Braestrup C, Schmiechen R Neef G, Nielsen M. Petersen
EN: Interaction of convulsive ligands with benzodiazepine
receptors. Science 216:1241, 1982.
3. Braestrup C, Squires, RE: Pharmacological charac-
terization of benzodiazepine receptors in the brain. Eur J
Pharmacol 48:263, 1978.
4. Burnham WM, Spero L, Okazaki MM, Madras BR
Saturable binding of 3H phenytoin to rat brain membrane
fraction. Can J Physiol Pharmacol 59:402, 1981.
5. Croucher MJ, Collins JF, Meldrum BS: Anticonvulsant
activity of excitatory amino acid antagonists. Science
216:899, 1982.
6. Frey H-H, Popp C, Loscher W: Influence of inhibitors of
high affinity GABA uptake on seizure thresholds in mice.
Neuropharmacology 18:581, 1981.
7. Gale K, Iadarola MJ: Seizure protection and increased
nerve-terminal GABA: Delayed effects of GABA transaminase
inhibition. Science 208:288, 1980.
8. Geller HM: Water soluble benzodiazepines with agonistic
and antagonistic actions on GABA-induced inhibition in cul-
tured hypothalamus. Neurosci Lett 15:313, 1979.
9. Geller 1 1M, Hoffer BJ, Taylor DA: Electrophysiological ac-
tions of benzodiazepines. Fed Proc 39:3016, 1980.
10. Haefely W, Bonetti EP, Burkard WP, Cumin R Laurent
JP. Mohler H, Fieri L, Pole P, Richards JG, Schaffner R
Schersehlicht R Benzodiazepine antagonists, in Costa E (ed),
Benzodiazepines — From Molecular Pharmacology to
Clinical Practice. New York , NY, Raven Press, 1983.
1 1. Leeb-Lundberg F, Snowman A, Olsen RW: Barbiturate
receptor sites are coupled to benzodiazepine receptors. Proc
Natl Acad Sci USA 77:7468, 1980.
1 2. Mohler 1 1, Okada T: Properties of 3H-diazepam binding
to benzodiazepine receptors in rat cerebral cortex. Life Sci-
ences 20:2101, 1977.
13. Nicoll RA. Eccles JC, Oshima T, Rubia F: Prolongation
of hippocampal inhibitory postsynaptic potentials by
barbiturates. Nature 258:625-627, 1975.
14. Okazaki MM, Madras BK, Livingston EK, Spero L,
Burham WM: Enhancement of 3H-phenytoin binding by
diazepam and ( + ) bicuculline. Life Science 33:409, 1983.
15. Niehoff DL, Mashal RE), Horst WD, O'Brien RA, Palacios
JM. Kuhar MJ: Binding of a radiolabeled triazolopyridazine
to a subtype of benzodiazepine receptor in the rat cerebellum.
J Phcirm Exp Ther 221:607, 1982.
16. Olsen RW, Leeb-Lundberg F, Napias C: Picrotoxin and
convulsant binding sites in mammalian brain. Brain Res
Bull 2:217, 1980.
17. Schmidt RF, Vogel ME, Zimmermann M: Die wirkung
von diazepam auf die prasynaptiche hemmund und andere
ruckenmarksreflexe. Naunyn-Schmiedeherg's Arch Pharma-
col 258:69, 1967.
18. Skerritt JH, Willow M, Johnston GAR Diazepam
enhancement of low affinity GABA binding to rat brain mem-
branes. Neurosci Lett 29:63, 1982.
19. Squires RF, Braestrup C: Benzodiazepine receptors in
rat brain. Nature 266:732, 1977.
20. Study RE, Barker JL: Diazepam and (-)-pentobarbital:
Fluctuation analysis reveals different mechanisms for poten-
tiation of -aminobutyric acid responses in cultured central
neurons. Proc Natl Acad Sci USA 78:7180. 1981.
21. Tallman JF, Thomas JW, Gallagher DW: GABAergic
modulation of benzodiazepine binding site sensitivity. Nature
274:383, 1978.
22. Ticku MK, Davis WC: Effect of valproic acid on 3H
dihydropicrotoxinin binding sites at the benzodiazepine-
GABA receptor-ionophore complex. Brain Res 223:218-222,
1981.
23. Willow M, Johnston GAR: Enhancement by anesthetic
and convulsant barbiturates of GABA binding to rat brain
synaptosomal membranes. J Neurosci 1:364, 1981.
24. Young WS III, Niehoff D, Kuhar MJ. Beer B Lippa AS:
Multiple benzodiazepine receptor localization by light micro-
scopic radiohistochemistiy. J Pharmacol Exp Ther 216:425,
1981.
324
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Pediatric Briefs
Richard H. Rapkin, m.d., Franklin C. Behrle, m.d., Shyan C. Sun, m.d., Newark*
Pediatric Briefs are abstracted from the Newsletter, a continuing
medical education project of the Department of Pediatrics,
UMDNJ-New Jersey Medical School and the Children's Hospital
of New Jersey.
Taylor EM, et al.: Family and community factors as-
sociated with infant deaths that might be prevent-
able. Br Med J 787:871, 1983.
"For a child to be treated successfully the parents
first must recognize that he is ill and then must rec-
ognize the need to take action. Next, they must be able
adequately to communicate their anxieties to an ap-
propriate member of the health care service, and these
services must be able to recognize and respond to the
families’ needs." A detailed study was made of all
deaths between age 8 days and 2 years in Sheffield,
England, in a two-year period. All patients were
matched to living controls. Specific analysis was made
of families of children who died of treatable diseases.
These families had significantly greater numbers of
adverse social factors (domestic and financial prob-
lems, mother and father’s upbringing, housing,
mother and father’s intelligence and state of health,
and family crises). The authors conclude that adverse
social factors play a substantial role in failure of identi-
fication of the presence of illness and inadequate
responses. These factors “are complex and not immedi-
ately susceptible to purely economic intervention or
necessarily to an unselective increase in primary
health care. Perhaps we should be more conscious of
the differing needs of individual families." The adverse
factors noted were related to the economic state but
appeared not to be related to social class.
Tager IB, et al.: Longitudinal study of the effects of
maternal smoking on pulmonary function in chil-
dren. N Engl J Med 309:699, 1983.
A careful study demonstrated that exposure to ma-
ternal smoking (passive) has substantial effects on
pulmonaiy function in children. This effect is seen in
children by the time they are aged 5 to 9 years. Paternal
smoking had little or no significance. Aside from the
obvious effect of “setting a bad example" leading to
subsequent smoking by the child himself, passive
smoking itself may have an important effect on the
development of COPD in adulthood.
Bensahel H, et al.: Bone scintigraphy in Perthes’ dis-
ease. J Pediat Orth 3:302, 1983.
Eighty-six percent of 71 hips with Perthes’ disease
were abnormal on bone scanning and were very speci-
fic for same. The scan was positive 4 to 6 weeks before
x-rays became abnormal and usually showed de-
creased or absent uptake in the head of the femur. The
scan never was falsely positive and was very sensitive.
The scan became normal far earlier than the radio-
* Abstracts are from the Department of Pediatrics Newsletter.
UMDNJ-New Jersey Medical School, Vol. 8. No. 12, 1983. Dr.
Rapkin is Editor and Medical Director of Children’s Hospital
of New Jersey, Newark. Coeditors are Dr. Behrle, Professor and
Chairman, Department of Pediatrics, UMDNJ-New Jersey
Medical School, and Dr. Sun, Director of Neonatology, Chil-
dren’s Hospital of New Jersey, Newark. Correspondence may
be addressed to Dr. Rapkin, Children's Hospital of New Jersey,
15 South 9th Street, Newark, NJ 07107.
VOL. 81— NUMBER 4— APRIL 1984
325
graph and therefore was helpful in prognosis and
treatment.
Comment: As the authors note, bone scanning is
very helpful in the differential diagnosis of hip pain,
in addition to being specifically helpful in Perthes' dis-
ease.
Gross RH, et al.: Early management and decision
making for the treatment of myelomeningocele. Pedi-
atrics 72:450, 1983.
A mere generation ago, most children bom with
myelomeningocele died in infancy. Now, vigorous treat-
ment yields high rates of survival— and high rates of
continued morbidity. Here, as in other areas of rapid
therapeutic advance, what was once a matter of fate
is now a matter of choice. Should this particular child
be vigorously treated or allowed to die?
The authors carefully review some of the relevant
clinical and ethical literature. Against this background
they report the experience of their center (University
of Oklahoma) with a process for selecting which in-
fants should receive vigorous treatment. Over a five-
year period, 69 babies were evaluated, 36 of whom were
recommended for vigorous treatment. Of the 33 babies
for whom only supportive care was recommended, 5
were initially treated at the parents’ insistence, 2
underwent delayed vigorous treatment, 1 was treated
subsequently on a “crisis management” basis (after
survival due in part to meticulous care at home), and
1 was lost to follow up. The remaining 24 children died
between 1 and 189 days (mean 37 days) receiving only
supportive care.
The principal features of the decision process which
led to these outcomes are as follows: 1 ) parents made
the decisions following extensive informing and emo-
tional support by the team; 2) in no case in which the
parents refused treatment did the professionals feel
there was a strong case for treatment: 3) there was a
broadly multidisciplinary team; 4) there was consis-
tent primaiy care by one team member throughout; 5)
there was a firm belief that urgent surgical closure
usually is not required, thus delaying team evaluation
until after acute treatment; and 6) surgeons who are
not expected to maintain followup throughout growth
were excluded from urgent decisions regarding treat-
ment plans.
The authors asked themselves two questions about
their program: 1) Is it workable? and 2) Does it ad-
dress, in a reasonable fashion, the present ethical (and
legal) dilemma surrounding this issue? Both ques-
tions were answered with a confident, though ap-
propriately qualified, yes.
Comment: This is a superb article: clear, thoughtful,
and important. Both the program itself and the article
reporting it reflect a balance between boldness and
care, between self-reliance and social responsiveness
that is so necessary to leadership in these matters.
Such qualities are not peculiar to Oklahoma One or
more New Jersey hospitals could add to the experience
needed for a technologically dazzling and thus morally
uncertain medical future.
The ethical values which seem to be emphasized in
the Oklahoma City approach are the right to privacy
(autonomy) and the avoidance of harm. The team not
only meticulously supports and informs the parents.
but shields them from pressures which might be ex-
pected to emphasize indications for urgent inter-
vention before deliberation. Wishes to “maintain hope"
or “avoid guilt" are not allowed to obscure the parents'
right to know the negative results of surgical ex-
perience as well as what surgical interventions often
have accomplished. Meanwhile, the whole approach is
based explicitly on an appreciation that there are cir-
cumstances in which life is not preferable to death and
that preservation of life at the cost of enormous suffer-
ing may sometimes be neither responsible nor loving
nor socially mandated.
In contrast, the Reagan Administration's Baby Doe
regulation emphasized the ethical principle of equity,
i.e. equal treatment for all classes of persons. The chief
evidence of the equity principle at work in the Okla-
homa experience is the apparent consistency of the
team's operation, affording to all parents of infants
bom with myelomeningocele equal access to an ap-
parently superb set of decision-making resources. (D.
Price, Ph.D., Adj. Asst. Professor, Health Care Human-
ities)
Yogman MW, et al.: Diet and sleep patterns in new-
born infants. N Engl J Med 309:1147, 1983.
Serotonergic transmission in neurons is associated
with sleep. Synthesis of serotonin is dependent upon
the availability of the amino acid tryptophan. Brain
tryptophan is dependent upon diet. Adults given phar-
macologic doses of tryptophan fall asleep more quickly
than with placebo. Newborns were studied comparing
a tryptophan feeding versus placebo (valine). Infants
fed tryptophan fell asleep more quickly and entered
quiet sleep sooner. The differences were very signifi-
cant.
Comment: Nature’s hypnotic! Soon we will need a
correlation with day and night variation in production
of tryptophan by the lactating mother. I'm not skep-
tical, just amazed that behavior and molecules are re-
vealing themselves to be so easily related. We will need
just an increase in x to become euphoric; an increase
in y to be more relaxed; for better SAT scores. What
next is in store for us?
Mulvihill S, et al.: Incidental appendectomy in in-
fants and children. Arch Surg 118:714, 1983.
Incidental appendectomy in infants and children
during clean abdominal procedures has been done
electively for many years in pediatric surgery. This
paper summarizes and confirms this conclusion, i.e.
that elective incidental appendectomy in the child
being operated upon for another abdominal condition
is well worth the few extra minutes spent.
Comment: In Children’s Hospital of New Jersey, we
have used this approach for at least 20 years. There
have been no related complications. In all cases, there
has been the procedure of inverting the stump or in-
verting the appendix. Opportunities to inspect the ap-
pendectomy site during a second surgical procedure
at a later date always revealed a clean smooth site of
the old appendectomy. This issue has been
emphasized by two recent cases in which a left-sided
acute appendicitis was diagnosed fortunately, and was
managed appropriately in patients with malrotation
who did not have incidental appendectomy when in-
itially operated on.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
326
DOCTORS’
NOTEBOOK
J
Trustees* Minutes:
^February 19, 1984
A regular meeting of the Board of
Trustees was held on Februaiy 19,
1984, at the Executive Offices in
Lawrenceville. Detailed minutes are
on file with the secretary of your
county society. A summary of sig-
nificant actions follows:
Report of the President . . .
No-Fault Insurance . . . Reaffirmed
opposition to any physician fee
schedule in regard to automobile in-
surance.
Report of Executive Director . . .
(1) MSNJ 1984 Paid Membership
. . . Noted that paid memberships at
the end of January totalled 4,400.
(2) Physician Reimbursement by
DRG . . . Noted that there is no in-
dication of any proposal to include
physicians under a DRG format at
Shore Memorial Hospital.
(3) Annual Meeting . . . Voted to
proceed with the Annual Meeting as
scheduled at Resorts International
Casino-Hotel.
(4) MSNJ Financial Statements
. . . Approved the financial state-
ments for the period ending Januaiy
31, 1984.
(5) Litigation Report . . .
(a) State Board of Medical Exam-
iners v Aluri; v Strauch . . . Noted
that the New Jersey Supreme Court
denied certification in the Aluri and
Strauch litigation; the issue of a
prejudiced forum and a merger of
functions must be corrected by legis-
lation.
(b) State Board of Medical Exam-
iners v Greco . . . Noted that oral
argument on the Greco case still is
pending in the Appellate Divison.
UMDNJ . . .
Physician Reimbursement by DRG
. . . Noted that Dr. Bergen men-
tioned that nothing actively was
being developed at this time on
either models or testing of DRGs to
include physicians in Medicare pay-
ments.
NJ Hospital Association . . .
Definition of a Health Care Facility
. . . Agreed to accept the concept of
a dinner-meeting format with the
Board of Trustees of MSNJ and
NJHA to discuss the proposed legis-
lative definition of a health care fa-
cility.
Executive Subcommittee, Commit-
tee on Impaired Physicians . . .
(1) Restructure of the Committee
. . . Approved the restructuring of
the Committee on Impaired Phy-
sicians to include: Executive Sub-
committee and General Committee
Membership (previously referred to
as panel of intervenors/monitors),
with Executive Subcommittee mem-
bers meeting four times a year and
the General Committee members to
meet at least twice a year.
(2) Employment of a Certified Al-
coholism Counselor . . . Approved
the following recommendation:
That the Board of Trustees approve the
position and employment of a certified
alcoholism counselor for the Impaired
Physicians Program.
Special Committee on Long-Range
Planning and Development . . .
Direct Candidacy for Elective Of-
fice . . . Approved the following rec-
ommendation:
That the Nominating Committee de-
velop a slate of two candidates for the
position of Judicial Councilor.
Disapproved the following three rec-
ommendations:
That the Nominating Committee de-
velop a slate of two candidates for the
position of Treasurer.
That the Nominating Committee de-
velop a slate of two candidates for the
position of Secretary.
That the Nominating Committee de-
velop a slate of candidates for the pos-
ition of Second Vice-President.
Disapproved unanimously the fol-
lowing two recommendations:
That the Nominating Committee de-
velop a slate of two candidates for the
position of First Vice-President.
That the Nominating Committee de-
velop a slate of two candidates for the
position of President-Elect.
Was not in favor of the following rec-
ommendation:
That the Nominating Committee de-
velop a slate of two candidates for each
Trustee position.
Committee on Medical Aspects of
Sports . . . Approved the following
recommendation:
That the Commissioner of Education
and the Division of Special Needs Handi-
capped Education be urged to adopt
guidelines for the school system that all
Down’s syndrome children be required to
have x-rays of the cervical spine, to evalu-
ate the presence or absence of the atlan-
toaxial condition prior to being per-
mitted to participate in any activity re-
sulting in hyperextension, radical flex-
ion, or direct pressure on the neck or
upper spine.
Specialty Society Representation
in MSNJ House of Delegates . . .
Approved the seating of the follow-
ing specialty societies in the House
of Delegates: New Jersey Chapter,
American College of Surgeons; New
Jersey Orthopaedic Society; New Jer-
sey Society of Internal Medicine;
New Jersey Academy of Ophthal-
mology and Otolaryngology; and
Radiology Society of New Jersey. Did
not approve the admission of the
American College of Physicians of
New Jersey. Approved the seating of
the following specialty societies in
the House of Delegates: New Jersey
Dermatological Society; New Jersey
Gastroenterological Society; New
Jersey Neurosurgical Society; Neu-
rological Association of New Jersey;
Urologic Society of New Jersey; New
Jersey Society of Plastic and Re-
constructive Surgeons; New Jersey
Society of Thoracic Surgeons; and
Oncology Society of New Jersey.
VOL. 81— NUMBER 4— APRIL 1984
327
Old Business . . .
1985 Annual Meeting . . . Referred
to the Committee on Annual Meet-
ing communications from Middle-
sex County Medical Society, Morris
County Medical Society, and Passaic
County Medical Society concerning
the 1985 Annual Meeting, and a re-
quest that the Committee develop a
questionnaire for distribution at the
upcoming meeting on the issue of
where the 1985 Annual Meeting
should be held.
(2) Medicaid Personal Physician
Plan . . . Approved the recommen-
dation that MSNJ does not endorse
the Medicaid Personal Physician
Plan being tested in Morris, Sussex,
and Warren Counties. Directed that
the State Commissioner of Human
Services be advised of MSNJ's pos-
ition.
(3) Peer Review Organizations . . .
Referred to the Ad Hoc Committee
on Study of PRO, a communication
from Passaic County Medical So-
ciety expressing opposition to MSNJ
becoming the prime contractor for
statewide peer review organizations.
New Business:
(1) Membership of the Committee
on Peer Review (DRG Appeals) . . .
Directed all county medical societies
be notified that if they wish rep-
resentation on the Committee on
Peer Review (DRG Appeals) they
should name an individual to serve
in that capacity, to be appointed by
MSNJ’s president.
(2) Proposed Resolution for 1984
Annual Meeting . . . Approved for
submission by the Board to the
1984 House of Delegates a reso-
lution that MSNJ urges individual
physicians to pay the dues of their
medical assistants to the American
Association of Medical Assistants-
State of New Jersey, Inc.
(3) State Board of Medical Exam-
iners Proposed Rule . . . Approved
proposed rule N.JA.C. 13:35-2.13 —
Limited Privileges and Conditions of
Practice Permitted for a Graduate
Physician Pending Licensure; the
rule would allow limited privileges
for graduate physicians pending
licensure.
President’s Column
Alexander D. Kovacs, M.D.
How many are aware that the
United States is more socialistic
than other western countries who
formally have adopted socialistic
systems? The great lie of socialism
and its bedrock foundation is the
promise to provide for all citizens
equally. We all know that all men are
not inherently equal. Our Constitu-
tion promises only the right to
pursue happiness. Socialism at-
tempts to make all people equal
through redistribution of wealth.
Alexander D. Kovaes, M.D.
France and England are examples
of structural socialism wherein land
and the maehineiy of production are
property of the government and not
of the individual. In the United
States, we have functional socialism
which is more subtle and dangerous
to our liberty. Equality is expected to
be achieved by taxing the earners of
wealth to provide benefits for the
less advantaged. The essence of the
system is to promote social justice
by imposing and collecting huge
taxes.
Functional socialism almost is im-
possible to dismantle. There are too
many bureaucrats, welfare groups,
and politicians with vested interest
in continuing the redistribution of
wealth. We are approaching a total
welfare state but few will call it a
socialistic state.
The private enterprise system is
based on a realistic appraisal of
human nature. Socialism in its pure
form is based on an idealistic con-
ception of that nature. In this coun-
try, collectivist authorities use legis-
lative pressure to oblige us to con-
form to the ideal.
The private enterprise system is
one of individual freedom. No one
has to be forced to act in his own
self-interest; it comes naturally. The
system is more productive since
each person's efforts will have a
great measurable effect on his own
situation. In the collective society,
the citizen is motivated by fear
rather than by any hope of personal
gain. Proponents of such systems
promise castles in the air and deliver
earthly prisons. Yet, they remain ob-
stinate in their error, despite dec-
ades of experience which prove the
inefficacy of the system.
What has this to do with medi-
cine? Note the changes occurring in
our profession. We are slowly but
surely being converted into a social-
ized medical system via cost effec-
tiveness, competitive regulations,
judges and juries, politicians, in-
surance companies, businesses, and
unions. Eveiyone preaches quality
medical care, no one wants to pay for
it.
In the United States, regulations
governing the practice of medicine
and the provision of health care
have become burdensome, inflexible,
and restrictive. Misunderstanding,
misinformation, and mistrust
abound and there is a reluctance on
the part of too many in medicine to
actively and individually counter
this destructive situation. We are so
busy protecting and promoting our
own specialties that we have lost
sight of the overall picture. We gen-
erally have been unwilling to be in-
volved in any significant effort to
help sell the very system which al-
lows us to sell our services to the
profit of our patients and ourselves.
We must stop treating public rela-
tions as a side issue. We must meet
the challenge of enlisting public
support. We must write and speak to
the public in such a way that the
person on the street can understand
what we say. We must provide medi-
cal care at reasonable cost and dem-
onstrate that the government can-
not do the job for less. The public
must be taught the folly of tinkering
with the system by calling for more
government intervention.
Why the hostility toward physi-
cians that focuses on the ability to
make a good living? Why does the
media constantly convey that we are
taking bread from the mouths of the
poor? Commentators and public fig-
ures like Senator Kennedy portray
us in the national media as money-
hungry professionals with no regard
for the health of our patients. Who
mentions the lives we save or the
i
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
328
money we save the public by keeping
them well and productive?
Can we alter what seems to be the
inexorable cycle of events? We know
what has happened in England and
elsewhere. We know it, yet we con-
tinue to march toward it. Once in
America we did take charge of our
destiny and, in less than 200 years,
we created a standard of living
which had never been dreamed of as
possible. We must be willing and
proud to fight for freedom again.
There can be no personal freedom,
no religious freedom, and no politi-
cal freedom without economic free-
dom! We must win the battle of
ideas!
To those who say there is nothing
we can do, I offer the words of Plato:
“The punishment of wise people
who refuse to be involved in the af-
fairs of government is to be governed
by unwise people.”
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
Obtaining objective data for the
diagnosis and treatment of mental
disorders long has been an elusive
goal for the field of psychiatry. Now,
Leonide Goldstein, D.Sc., professor
of psychiatry at UMDNJ-Rutgers
Medical School, feels specialists at
the Community Mental Health
Center, Piscataway, are a step closer
to developing an objective method.
By using an electroencephalogram
(EEG), a patient's brain waves are
amplified, recorded on paper, and
fed into a computer for analysis. In
most cases, the procedure enables
researchers to recognize if a person
is suffering from mental illness and,
if so, what kind. The EEG also charts
what changes — if any— have oc-
curred as a result of treatment.
Electrodes are attached to six
areas of the scalp and patients then
are asked to perform one of a
number of thinking functions, such
as concentrating on words or im-
ages.
Active thinking processes result
in differently directed changes be-
tween the activities of the two
cerebral hemispheres. In paranoid
schizophrenics, for example, there is
a clear-cut abnormality in the left
hemispheric function. They perform
visual functions well, but not verbal
ones. In patients who are depressed,
the opposite is true. The right hemi-
spheric function is abnormal, and
they perform verbal tasks better
than those of a visual nature.
Once the mental illness and its
severity are diagnosed, the EEG
then is used to test the efficacy of
treatment. When successful, a re-es-
tablishment of normal brain pat-
terns during drug treatment usually
is seen.
A new laboratory at UMDNJ-
Rutgers School, Piscataway, is
providing physicians and hospitals
with analysis and diagnosis of con-
ditions ranging from acquired im-
munodeficiency syndrome (AIDS)
and hepatitis to infertility and
cancer.
Under the direction of Karel F.
Raska, Jr., M.D., Ph.D., professor of
pathology and microbiology, the
diagnostic laboratoiy features the
state’s only operational Cytofluoro-
graf available for direct patient care.
Manufactured by Johnson & John-
son, the instrument provides rapid
analysis reported back within 24
hours, and the laboratoiy provides
courier service throughout the state.
By marking blood specimens with
monoclonal antibodies tagged with
a dye sensitive to the machine’s two
lasers, researchers are able to de-
termine the amount of specific
lymphocyte types or other cell types
present in a patient’s white blood
cells.
The clinical immunology division
of the laboratory currently serves
Middlesex General-University Hospi-
tal and St. Peter's Medical Center,
New Brunswick, as well as Somerset
Medical Center, Muhlenberg Hospi-
tal, and the VA Hospital, Lyons.
A comprehensive sickle cell
anemia program has been initiated
at the Newark campus of UMDNJ.
Under the direction of Prakash
Kaur, M.D., assistant professor of
pediatrics at UMDNJ-New Jersey
Medical School, the endeavor will
combine treatment, education, gen-
etic counseling, psychosocial sup-
port, screening, and clinical and
biomedical research in its battle
against this inherited blood dis-
order.
The disease occurs in one of every
500 to 600 births among black
people.
The program provides clinical care
for children and adolescents under
20 at four participating Newark hos-
pitals: UMDNJ’s University Hospital,
Children's Hospital of United Hospi-
tals Medical Center, Newark Beth Is-
rael Medical Center, and Saint
Michael’s Medical Center. Education
and community outreach compo-
nents are being coordinated by the
Sickle Cell Foundation of New Jer-
sey.
Currently, the key catchment area
for medical care is Newark and the
surrounding communities. Educa-
tion, screening, and counseling ef-
forts will blanket Essex, Hudson,
Middlesex, and Union counties, and
patient referrals will be accepted
from anywhere in the state. The pri-
mary inpatient units are at Univer-
sity Hospital’s hematology service
and at Children’s Hospital, both of
which provide around-the-clock care
to patients.
Children with the disease receive
outpatient care for routine check-
ups and parental consultation every
6 to 12 weeks. An afternoon clinic
has been started so that children
can be seen after school.
The sickle cell program also has
an educational component for pro-
fessionals, consisting of conferences
and lectures on cases and updates.
Participants are physicians, hospi-
tal staff, and medical students.
MSNJ Auxiliary
Gale Wayman
President
Several months ago, while reading
The Healing Heart by Norman
Cousins, it became more and more
apparent that this book would be
excellent reading for the medical
community.
Although written for the layman,
this book addresses many of the
problems that face the physician
today. The author is in the unique
position of being a member of the
faculty of a medical school, UCLA
Medical School, and a patient who
suffered a heart attack at the same
institution. Cousins’s special field of
study has been the biochemistiy of
emotion, and he especially is
interested in the way attitudes and
emotions can bring on disease or
improve the prospects of recovery.
The author has articulated many
problems that face the physician
and gives a new way of meeting
these problems. Today, the phy-
sician deals with better educated
and more sophisticated patients
VOL. 81— NUMBER 4— APRIL 1984
329
who want to participate in decision-
making concerns about their own
health care.
"Health" now is news! Every night
on television, the public hears about
the latest medical discoveries; entire
magazines are devoted to health;
and entire stores cater to health care
needs. While patients are partici-
pating more in their own care, they
also are suing more, and there has
been an eruption of malpractice
suits. At the same time, physicians
are expected to use new technology;
they also are expected to keep health
care costs down. These are but a few
of the problems that are addressed
in The Healing Heart. It may not
have all the answers, but it is a great
start!
The Auxiliary will have this book
available for $10 to sell as a fund-
raiser during the convention in At-
lantic City. Please look for it!
AMNJ Report
Paul J. Hirsch, M.D.
President
The Board of Trustees of the
Academy of Medicine of New Jersey
has named the 1984 recipients of
the awards which will be presented
at our Annual Dinner on Wednes-
day, May 23, 1984, to be held at the
Chanticler in Short Hills.
Alfred A. Alessi, M.D., will receive
the Edward J. Ill Award “presented
annually to that physician of New
Jersey who merits recognition by
the Academy for distinguished ser-
vice as a leader in the medical pro-
fession and in the community at
large." Recent recipients have in-
cluded Doctors Leon Smith, Arthur
Krosnick, James Todd, and Arthur
Bernstein. Dr. Alessi is a past presi-
dent of the Medical Society of New
Jersey, and is an AMA delegate. He
also is chairman of the Education
Committee of the Academy of Medi-
cine. He serves on many boards and
committees, and is a frequent
speaker on topics of interest to the
medical community.
The Academy's Citizen's Award is
"presented annually to that citizen
or group of citizens of New Jersey
who merit recognition by the
Academy for distinguished service
in the interest of the health and wel-
fare of the community at large." The
1984 Citizen's Award has been
granted to Congressman James
Courter. Mr. Courter has demon-
strated an overwhelming commit-
ment to the health needs of the
citizens of New Jersey. He particu-
larly has been active in efforts to in-
crease public awareness and fund-
ing for organ transplants. He also
has been very much concerned
about the health needs of the elderly
and has been able to play an active
role in this problem through his
position on the House Aging Com-
mittee. He has talked before Con-
gress to focus attention on the
tragedy of Alzheimer's disease. He
also has been active in efforts to deal
with drunken driving and drug
abuse. He has worked to protect
health benefits for veterans, and has
sponsored legislation expanding
coverage for victims of Agent Or-
ange.
The Academy of Medicine’s An-
nual Dinner, at which these awards
will be granted, is a major event in
the Academy’s calendar. Last year,
this dinner was oversubscribed;
many requests for reservations had
to be declined. We expect a similar
large number this year to honor
these outstanding recipients.
Mr. Charles Heitzmann, Executive
Director of the Academy of Medicine,
and I attended the 9th Annual Meet-
ing of the Alliance for Continuing
Medical Education. This meeting
focused on the need for organiza-
tions to help physicians individ-
ualize their educational programs,
so as to be most pertinent to their
own practices. Our approach to
CME has been changing rapidly, be-
cause of the same pressures that af-
fect other aspects of medicine, and
because of advancing technology.
The standard approaches of meet-
ings, conferences, and seminars
(usually large, long, and far away) do
not seem to meet the needs of phy-
sicians today. Cost factors increas-
ingly are more important. Funding
for hospital CME programs is ex-
pected to diminish under the federal
DRG system. These same factors
may decrease funds available to full-
time physicians to attend educa-
tional programs which require
travel. There is a trend today for
education to be closer to home, to be
more directly related to the individ-
ual's practice, and to use modem
technology. Furthermore, since only
about 6 percent of medical mistakes
relate to a lack of knowledge, there
is agreement that CME must relate
not only to knowledge, but to chang-
ing behavior. “Individualized CME"
may include counseling services
provided by organizations to help
the individual detennine those pro-
grams and processes which are
most suitable to a specific educa-
tional need. The concept of tailoring
CME to the individual physician is
not a new one, but it is gaining in
popularity and we are likely to hear
more of it in the future.
The speaker at the Februaiy First
Wednesday program was James
Todd, M.D. On March 7, 1984, the
First Wednesday speaker was
Charles Whelan, M.D. His topic was,
“Does Governmental Control in the
Purchase of NMRs Have an Impact
on the Future of the Private Office
Practice of Medicine?”
New Members
The Journal would like to wel-
come the following members to the
Medical Society of New Jersey:
Bergen County
Hormoz Ashtyani-Asl, M.D., Fair
Lawn
JoAnne Betta, M.D., Tenafly
Dennis P. Daut, M.D., Ridgewood
Sybil E. N. Duchin, M.D., Ridgewood
Mitchell S. Engler, M.D., Teaneek
Ira Esformes, M.D., Westwood
Edward Fass, M.D., Fort Lee
Martin A. Fechner, M.D., Teaneek
Howard L. Frey, M.D., Midland Park
David V. Habif Jr., M.D., Teaneek
Hariy D. Harper, M.D., Englewood
Jerald B. Hershman, M.D., Allendale
Andrew R. Herzog, M.D., Wyckoff
George B. Leber, M.D., Englewood
John M. Lloyd, M.D., Westwood
Jacqueline S. Lustgarten, M.D., River
Edge
Suri B. Ponamgi, M.D., Fort Lee
Glenn R. Silbert, M.D., Hackensack
Robert E. Waidmann, M.D., Fort Lee
Stanley E. Waintraub, M.D.,
Englewood
Steven J. Weisholtz, M.D., Leonia
Burlington County
Richard M. Goldstein, M.D., Medford
Lakes
Vicky LA. Mitruka, M.D., Willingboro
Kenneth D. Schulner, M.D.,
Willingboro
Camden County
Ivan F. Ackerman, M.D., Camden
Clifford J. Ameduri, M.D., Camden
Frederick L. Ballet, M.D.,
Haddonfield
330
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Jessica P. Byrne, M.D., Camden
Carolyn S. Crawford, M.D., Camden
Elizabeth Fond-DeLeon, M.D.,
Camden
M. Arif Hashmi, M.D., Cheriy Hill
Emily S. Miller, M.D., Haddon
Heights
Franklin I. Rosenberg, M.D.,
Voorhees
Cape May County
Donald F. Lyle, M.D., Ocean City
Cumberland County
Kathleen W. McNieholas, M.D.,
Browns Mills
Steven L. Rodis, M.D., Bridgeton
Vincent J. Taormina M.D., Cheriy
Hill
Essex County
Neil H. Adelman, M.D., Millbum
Kenneth S. Bannerman, M.D., Glen
Ridge
Kenneth Cubelli, M.D., Fairfield
Gaiy C. DeGrande, M.D., Glen Ridge
Luis M. Guerra, M.D., Belleville
Thomasina Ivey, M.D., Newark
Frank L. Kane, M.D., Verona
Dominick J. Ligresti, M.D., Belleville
Howard Louis, M.D., Upper
Montclair
Madhavi N. Maniar, M.D., East
Orange
Bernard J. Manney, M.D., Caldwell
Daniel D. Manzi, M.D., South Orange
Henry J. McCabe, M.D., Maplewood
William Oppenheim, M.D., Roseland
Thomas R. Ortiz, M.D., Verona
Frank T. Padberg Jr„ M.D., Newark
Paul Paroski Jr„ M.D., Newark
Barry R Seidman, M.D., Millbum
Michael P. Wujciak, M.D., Bloomfield
Gloucester County
Robert J. Cales, M.D., Mantua
Karl H. Ebert, M.D., Cheriy Hill
Lawrence K. Epple Jr„ Woodbury
Heights
Hudson County
Subbian Dharmalingam, M.D.,
Mountainside
Pierre Guibor, M.D., New York, NY
Young W. Kim, M.D., North Bergen
Joseph Zicarelli, M.D., Staten Island,
NY
Hunterdon County
Gerald E. Batt, M.D., Flemington
Robert G. Coates, M.D., Hampton
Jeremy C. Hewens, M.D., Milford
Brian M. Quinn, M.D., Flemington
Mercer County
Byung-Kee Bang, M.D., Trenton
Robert S. Collins, M.D., Trenton
Jay R. Goldstein, M.D., Trenton
Middlesex County
Gloria A. Baehmann, M.D., Edison
Young K. Cho, M.D., Staten Island,
NY
Leo A. Fabbro. M.D., Metuchen
Kerry M. Fagelman, M.D., New
Brunswick
Stephen J. Gordon, M.D., New
Brunswick
Malvin S. Keller, M.D., Edison
Sanford L. Klein, M.D., New
Brunswick
Ashok Kumar, M.D., Highland Park
Wen Jung Lin, M.D., Milltown
Harold V. McKenna M.D., South
Amboy
Erwin Mermelstein, M.D., Highland
Park
Arthur Miller, M.D., East Brunswick
Anthony J. Passannante Jr., M.D.,
Metuchen
Allan B. Plumser, M.D., Somerset
Andrew B. Sachere, M.D., Somerset
Peter M. Scholz, M.D., New
Brunswick
Gregoiy E. Scott, M.D., New
Bmnswick
Praful M. Shah, M.D., Piscataway
Edward J. Walkowski Jr„ M.D., Old
Bridge
Monmouth County
Hugo Jose M. Cerri, M.D., Freehold
Stephen T. Dudick, M.D., Red Bank
Robert G. Josephberg, M.D.,
Freehold
Wai Hung Edmund Kwong, M.D.,
Red Bank
Kenneth P. Lipkowitz, M.D., Howell
William K. Power Jr„ M.D., Ocean
Grove
Tsui H. Rangam, M.D., Irvington
Sanford H. Vemick, M.D., Red Bank
Morris County
Mark E. Maletsky, M.D., Rockaway
Pradip Sahdev, M.D., Morristown
Ocean County
Mathew K. Kandathil, M.D.,
Lakewood
Yeshavanath P. Nayak, M.D., Toms
River
Joseph P. Padula, M.D., Pt. Pleasant
Passaic County
Joseph B. Baratta, M.D., Clifton
Peter M. Crain, M.D., Paterson
Amir Ghandchi, M.D., Wayne
James M. Hyde, M.D., Paterson
Ernest D. Kirrer, M.D., Clifton
Somchai Kulwatdanaporn, M.D.,
Paterson
Jeffrey I. Marder, M.D., Paterson
Warren L. Maresca, M.D., Paterson
Evangelos Megariotis, M.D., Clifton
Robert A. Schultz, M.D., Paterson
David Scolnick, M.D., Paterson
Joseph A Tarta, M.D., Wayne
Salem County
Domenic F. Coletta, M.D., Salem
Devendra M. Jani, M.D., Salem
Union County
Paul J. Camiol, M.D., Summit
Michel-Ange Ferdinand, M.D.,
Elizabeth
Eve Anne Feret, M.D., Newark
Mark S. Gold, M.D., Summit
Ilia Segal, M.D., Hillside
Michael B. Wax, M.D., Summit
Warren County
William P. Braun III, M.D.,
Phillipsburg
IlaA. Shal, M.D., Phillipsburg
Dennis R. Filippone: The
Maimonides Award
Recipient
Congratulations are in order for
Dennis R. Filippone, M.D. The State
of Israel Bonds-Medical Arts
Division has selected him for its
prestigious Maimonides Award. The
citation reads: “For notable leader-
ship and outstanding participation
in the Health Professions and Ser-
vice Division of Israel Bonds and for
devoted support of the vital program
to develop the economy of the state
of Israel as a means of realizing its
hopes for a future of peace and prog-
ress.”
Dr. Filippone, the surgical director
of the Renal Transplant Service at
Saint Barnabas Medical Center, Liv-
ingston, is a member of our Essex
County component and of the
American Medical Association. He
will be the next president-elect of the
Academy of Medicine of New Jersey..
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
VOL. 81— NUMBER 4— APRIL 1984
331
ALCOHOLISM— George W. Miller Jr.,
M.D.. 77 Grove St., Apt. 8, Montclair, NJ
07042. UMDNJ 1980. Available July
1984.
ANESTHESIOLOGY— Jan Charles 1 lor
row, M.D., 131 Pond Brook Rd„
Chestnut Hill, MA 02167. Penn-
sylvania 1977. Board certified. Group,
academia, HMO. Available.
CARDIOLOGY— Aubrey Orrin Lewis,
M.D., 200 Carman Ave„ Apt. 21-F, East
Meadow, NY 11554. SUNY-Syracuse
1979. Also, general internal medicine.
Board certified (IM). Solo, partnership,
group, academia (cardiology). Available
July 1984.
FAMILY MEDICINE— Jaime F. Lara
M.D., 6045 Palisade Ave., West New
York, NJ 07093. Seville (Spain) 1979.
Board eligible. Partnership or institu-
tionally based. Available.
GASTROENTEROLOGY— Albert M
Harary, M.D., 2121 N. Bayshore Dr.,
Apt. 1001, Miami, FL 33137. Columbia
1978. Also, general internal medicine.
Board certified (IM). Group, partner-
ship, solo. Available July 1984.
Prakash V. Huded, M.D., 80-15 41 Ave.,
# 606, Elmhurst, NY 1 1373. Kamatak
(India) 1970. Board certified. Solo,
group, partnership. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, internal medicine. Part-
nership, group, full-time hospital.
Available July 1984.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia MO 6520 L National Taiwan
University 1977. Also, internal medi-
cine. Board certified. Available July
1984.
INTERNAL MEDICINE— Nicholas
Bertini, M.D., 663 Hudson Ave., Albany,
NY 12203. SUNY-Buffalo 1980. Board
eligible. Group, partnership, solo. Avail-
able June 1984.
Harold J. Brown, M.D., 260 Eggerts Rd.,
Lawrenceville, NJ 08648. UMDNJ 1982.
Primary care clinic, HMO, group, part-
nership. Available July 1985.
Palamadai S. Duraiswami, M.D., 64-A
Oneida Ave., Centereach, NY 11720.
Stanley Medical College (India) 1976.
Board eligible. Available.
Z.UA. Farooqui, M.D., Plaza Pro-
fessional Bldg., Bayshore Rd. and
Greenwood Ave., Box 238, Villas, NJ
08251. Aurangabad Medical College
(India) 1972. Board eligible. Group or
partnership. Available.
Elliott Friedman, M.D., 25 Penny La,
Baltimore, MD 21209. SUNY-Syracuse
1978. Subspecialty, endocrinology.
Board certified (IM); board eligible (M).
Group or partnership (both special-
ties). Available July 1984.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, gastroenterology. Part-
nership, group, full-time hospital.
Available July 1984.
Andrew L. Saporito, Jr., M.D., 28
Grandview Ave., West Orange, NJ
07052. Guadalajara (Mexico) 1976.
Group or partnership. Available.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia MO 65201. National Taiwan
University 1977. Also, gastroenter-
ology. Board certified. Available July
1984.
Steven Wolinsky, M.D., 1404 E. 15 St.,
Brooklyn, NY 1 1 230. Case Western Re-
serve 1980. Group or partnership.
Available July 1984.
NEPHROLOGY— Arvind Mehta M.D.,
8051 N. Hanover St., Anaheim, CA
92861. Seth G.S. Medical College
(India) 1975. Also, internal medicine.
Board eligible. Solo, group, partner-
ship. Available.
NEUROLOGY— Elizabeth Kamenar,
M.D., 12701 Shaker Blvd., Apt. 410,
Cleveland, OH 44120. Ohio State 1975.
Board eligible. Group, partnership,
academia Available July 1984.
Robert P. Rubens, M.D., 105 Ward St.,
Apt. 204, Seattle, WA 98109. UMDNJ-
New Jersey Medical School 1980.
Board eligible. Available July 1984.
OBSTETRICS/GYNECOLOGY— Alan M.
Askinas, M.D., 1309 Carrollton, Apt.
321, Metairie, LA 70005. Illinois 1980.
Board eligible. Group, partnership,
solo, part academia. Available July
1984.
OPHTHALMOLOGY— Steven R Davis,
M.D., 1000 Lakeview Rd., Clearwater,
FL33516. University of Alabama 1975.
Board certified. Solo or association.
Available.
Andrew Gewirtz, M.D., 519 Beach 133
St., Belle Harbor, NY 11694. Chicago
1978. Board eligible. Board certified
(PD). Group or partnership. Available
July 1984.
218th Annual Meeting
May 2-6, 1984
Resorts International
Atlantic City, New Jersey
Daily Schedule
Wednesday, May 2, 1984
3:30 p.m.— Board of Trustees’ Meeting
7:00 p.m.— Officers' Cocktail Reception followed by Dinner
Thursday, May 3, 1984
9:00 am.— Registration Opens
2:00 p.m. — House of Delegates
4:00 p.m.— Reference Committees (Three Reference Committee
Meetings)
Friday, May 4, 1984
7:30 am.— Registration Opens
9:00 am. —House of Delegates (election)
9:00 am.— Message Center, and Scientific, Informational, and
Insurance Exhibits Open
12:00 noon— Golden Merit Award Ceremony followed by Reception
2:30 p.m. — Reference Committees (Three Reference Committee
Meetings)
5:00 p.m. — JEMPAC Political Forum
5:45 p.m.— JEMPAC Wine & Cheese Reception
Saturday, May 5, 1984
8:00 am. — Registration Opens
9:00 am. —Message Center, and Scientific, Informational, and
Insurance Exhibits Open
9:00 a.m. — Scientific Sessions
12:00 noon — Luncheons
1:00 p.rn.— Scientific Sessions
6:30 p.m.— Inaugural Reception followed by Inaugural Dinner
Sunday, May 6, 1984
6:30 am.— County Society Breakfast Caucuses
8:00 am. — Registration Opens
9:00 am. — Message Center, and Scientific, Informational, and
Insurance Exhibits Open
9:00 am.— House of Delegates
3:00 p.m.— Board of Trustees’ Meeting
332
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
PATHOLOGY— Mark A. Grathwhol, M.D.,
2510 West Tremont Ct„ Richmond, VA
23225. NYU 1980. Group. Available
July 1984.
Yury Kogan, M.D., 60 Egmont St.,
Brookline, MA 02146. Moscow 1967.
Hospital or group. Available July 1984.
PEDIATRICS — Jonathon J. Evans, M.D.,
1800 Calvin Ct„ #6, Iowa City, LA
52240. Univ. of Califomia-San Diego
1981. Board eligible. Group or HMO.
Available July 1984.
Kusumam Sidharthan, M.D., 222
Yorkshire Ct„ Old Bridge, NJ 08857.
Calicut Medical College (India) 1976.
Board eligible. Available July 1984.
PSYCHIATRY— Eric M. Levin, M.D., 43
West 8th St., Media, PA 19063. La Fac-
ulty Libre de Medicine (Spain) 1980.
Board eligible. Group, institutionally
based, CMH outpatient. Available July
1984.
PULMONARY DISEASES— James
Kohan, M.D., 19 Highmanor Dr., Hen-
rietta, NY 14467. Virginia 1979. Also,
general internal medicine. Board
certified (IM). Group, partnership, solo,
institutional. Available July 1984.
Dinesh Talati, M.D., 66-02 Grand Cen-
tral Pkwy., Forest Hills, NY 1 1375. B.J.
Medical College (India) 1974. Board
eligible. Solo, group, partnership. Avail-
able July 1984.
RADIOLOGY/NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon
St., Apt. 3B, Brookline, MA 02146. Bos-
ton 1976. Board certified. Group or
partnership. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond
Brook Rd„ Chestnut Hill, MA 02167.
Medical College of Pennsylvania 1980.
Board eligible. Group, HMO, academia.
Available.
RHEUMATOLOGY— Richard Furie, M.D.,
435 E. 70th St„ Apt. 8-F, New York, NY
10021. Cornell 1979. Also, general
internal medicine. Board certified (IM).
Group, partnership, solo. Available July
1984.
SURGERY, GENERAL— F. Andrew
Morfesis, M.D., 7545 Rogers Ave.,
Upper Darby, PA 19082. Penn State
(Hershey) 1979. Board eligible. Avail-
able July 1984.
SURGERY, ORTHOPEDIC— Jeffrey H.
Charen, M.D., 155 Lexington St., Apt.
15, Aubumdale, MA 02166. Rochester
1978. Board eligible. Group, partner-
ship, solo (central or northern NJ
preferred). Available.
Richard Lebovicz, M.D., 415 Grand St.,
New York, NY 10002. SUNY-Downstate
1979. Group or partnership. Available
July 1984.
UROLOGY — Joseph G. Colonna, M.D.,
1234 Van Voorhis Rd„ Apt. C-6,
Morgantown, WV 26505. Guadalajara
(Mexico) 1977. Board eligible. Group or
partnership. Available October 1984.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NSCIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL(B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100
mg.
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mp. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug.
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding
Write for literature and samples
THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057
VOL. 81— NUMBER 4— APRIL 1984
Housing Application
218th ANNUAL MEETING
THE MEDICAL SOCIETY OF NEW JERSEY
MAY 3-6, 1984
Single
Twin
Suites
Resorts International
(headquarters hotel)
$80.00
$80.00
$1 71 /$250
Harrah’s Marina Hotel Casino
$75.00
$75.00
World International Hotel/Motel
$58.00
$58.00
Lafayette Motor Inn
$58.00
$58.00
Rates subject to 12% state and local taxes; tax subject to change.
All hotel reservations for the 218th Annual Meeting of MSNJ will be handled by the Atlantic City Convention
Bureau. Please send your housing application with your 1st, 2nd, and 3rd choices directly to the Bureau, 16 Central
Pier, Atlantic City, NJ 08401. All Delegates and Members are urged to make their hotel reservations early. Blocks
of rooms will be available at Resorts International (headquarters hotel), Lafayette Motor Inn, World International
Hotel/Motel, and Harrah’s Marina Hotel Casino. The cut-off date for reservations will be April 6, 1984. Reservations
cannot be guaranteed after this date. No Saturday arrivals please. All registrants will be charged for three nights:
Thursday, Friday, and Saturday, May 3, 4, and 5, 1984.
MAIL THIS APPLICATION DIRECTLY TO THE ATLANTIC CITY CONVENTION BUREAU
16 Central Pier
Atlantic City, NJ 08401
Please list 1st, 2nd, and 3rd choices; confirmation will come directly from hotel.
1st Choice 2nd Choice
3rd Choice
Accommodations desired: □ Single □ Twin □ Suite Parlor & 1 Bedroom
□ Suite Parlor & 2 Bedrooms
Name
Address
City
Phone
Will arrive Time
date
□ Check if Official Delegate
334
State Zip
Will depart Time
date
County
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Report of the Nominating Committee
Offices To Be Filled By Election— 1984 Annual Meeting
Office
Term
Nominee and County
President-Elect
1 year
Ralph J. Fioretti, M.D., Bergen
First Vice-President
1 year
Edward A. Schauer, M.D., Monmouth
2nd Vice-President
1 year
Hariy M. Carnes, M.D., Camden
Trustees:
1st District
3 years
Douglas M. Costabile, M.D., Union
1st District
3 years
Bernard Robins, M.D., Essex
2nd District
3 years
Carl Restivo, Jr„ M.D., Hudson
2nd District
3 years
Gerald H. Rozan, M.D., Passaic
3rd District
3 years
Michael M. Heeg, M.D., Mercer
3rd District
3 years
Palma E. Formica, M.D., Middlesex
4th District
3 years
John P. Kengeter, M.D., Ocean
Judicial Councilors:
3rd District
1 year
Frank Campo, M.D., Mercer
1st District
3 years
Edward M. Coe, M.D., Union
4th District
3 years
Frederick W. Durham, Camden
AMA Delegates:
2 years
Alfred A, Alessi, M.D., Bergen
2 years
Frederick W. Durham, M.D, Camden
2 years
Palma E. Formica M.D., Middlesex
2 years
Karl T. Franzoni, M.D., Mercer
2 years
John S. Madara, M.D., Salem
2 years
Hemy J. Mineur, M.D., Union
AMA Alternate Delegates:
Vi year*
Joseph A. Riggs, M.D., Camden
2 years
Joseph A. Riggs, M.D., Camden
2 years
Augustus L. Baker, Jr„ M.D., Morris
2 years
Charles S. Krueger, M.D., Burlington
2 years
Carl A. Restivo, Sr„ M.D., Hudson
2 years
Robert H, Stackpole, M.D., Union
Delegates and Alternate Delegates to Other States:
New York:
Delegate
1 year
F. Sterling Brown, M.D., Atlantic
Alternate
1 year
John J. Pastore, M.D., Cumberland
Connecticut:
Delegate
1 year
Frank R Romano, Sr„ M.D., Union
Alternate
1 year
Gastone A. Milano, M.D., Altantic
Administrative Councils:
Legislation:
5th District
3 years
L. Willis Allen, M.D., Cumberland
6th Member
3 years
Howard H. Lehr, M.D., Union
Medical Services:
5th District
3 years
John J. Pastore, M.D., Cumberland
6th Member
3 years
Frank A Wolf, M.D., Warren
Mental Health:
3rd District
3 years
Joseph J. Kline, M.D., Mercer
6th Member
3 years
William R. Nadel, M.D., Union
Public Health:
5th District
3 years
Narasimhaloo Venugopal, M.D., Cumberland
6th Member
3 years
Glenn P. Lambert, M.D., Hunterdon
Public Relations:
2nd District
3 years
Joseph W. Bitsack, M.D., Bergen
5th District
3 years
John J. Pastore, M.D., Cumberland
Standing Committees:
Annual Meeting
3 years
Thomas J. Connolly, Jr„ M.D., Hudson
Auxiliary Advisory
3 years
J. James Pegues, M.D., Burlington
Finance and Budget
3 years
Harry M. Carnes, M.D., Camden
Medical Defense and Insurance
3 years
E. Arthur Kratzman, M.D., Union
Medical Education
3 years
Edwin W. Messey, M.D., Burlington
Publication
3 years
Dirck L. Brendlinger, M.D., Burlington
*Unexpired term of Daniel J. O'Regan, M.D., deceased
VOL. 81— NUMBER 4— APRIL 1984
335
ANNUAL AWARDS DINNER
of
THE ACADEMY OF MEDICINE
OF NEW JERSEY
Wednesday, May 23, 1984
6:00 P.M.
at
THE CHANTICLER
Short Hills, New Jersey
1984 AWARD RECIPIENTS
EDWARD J. ILL AWARD
ALFRED A. ALESSI, M.D.
CITIZENS AWARD
CONGRESSMAN JAMES COURTER
(R-12th District)
For further information, please contact:
6emyo/. EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
5 Two Princess Road
n Lawrenceville, NJ 08648
of New Jersey (609) 896-1717
June 16, 1984
4th Annual Advances
in Gastroenterology
Golden Nugget Hotel
Atlantic City, New Jersey
Sponsored by the Gastrointestinal Section
of the Hospital of the
University of Pennsylvania
and
the Continuing Medical Education
Department of the
Underwood Memorial Hospital
Woodbury, New Jersey
Category 1 credit offered
Information: Registration Supervisor, SLACK In-
corporated, 6900 Grove Road, Thorofare,
New Jersey 08086, 609-848-1000
. . University of Pennsylvania
School of Medicine
336
II 1C IHIIII nf it:
IWSIMfl'S E llllil
Course Director: Patrick B. Storey, M.D.
Associate Dean for Continuing
Medical Education
A 3-day program that will provide you, the practic
ing physician, with the information you need to
make informed judgments about automating your
office.
Approved for 18 Category 1 credit
hours of the Physician's Recogni-
tion Award of the American Medical
Association and 18 prescribed
hours by the AAFP.
For further information, contact:
Haney Wink, Program Director
Continuing Medical Education
(215) 898-8005
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CME CALENDAR
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
This list is compiled through the coop-
eration of the Committee on Medical
Education of the Medical Society of New
Jersey, the Academy of Medicine of New
Jersey, the New Jersey Chapter of the
American Academy of Family Phy-
sicians, and the Office of Continuing
Medical Education of the UMDNJ. For
information on accreditation, please
contact the sponsoring organization (s),
indicated by italics— last line of each
item.
ANESTHESIOLOGY
May
1 Anesthesia Lectures
8 4-5 P.M. — NJ Medical School.
15 Newark
22 (UMDNJ)
2 Anesthesia Grand Rounds
9 4-5 P.M. —University Hospital,
16 Newark
23 (UMDNJ)
30
7 Anesthesia Lectures
14 7-8 A.M.— NJ Medical School,
21 Newark
(UMDNJ)
June
4 Anesthesia Lectures
11 7-8A.M. — NJ Medical School,
18 Newark
25 (UMDNJ)
5 Anesthesia Lectures
12 4-5 P.M. — NJ Medical School,
19 Newark
26 (UMDNJ)
6 Anesthesia Grand Rounds
13 4-5 P.M. — University Hospital,
20 Newark
27 (UMDNJ)
CARDIOLOGY
May
1 Vascular Conference
9 4-5 P.M. — NJ Medical School
16 MSB C 600
23 (UMDNJ)
30
2 Recent Advances in
Echocardiology
1 -2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
2 Cardiovascular Evaluation and
Treatment of Patients with
Recurrent Syncope
9-1 1 P.M. — Middlesex General
Hospital. New Brunswick
(Middlesex General-University
Hospital and AMNJ)
5 Advanced Echocardiography
6 9 A.M. -5 P.M. —Center for Health
Affairs, Princeton
(The National Foundation JorNon-
invasive Diagnostics and AMNJ)
9 Preventive Cardiology Seminar
23 12 noon- 1 P.M. —NJ Medical School,
Newark
(UMNDJ)
19 Prosthetic Cardiac Valves
20 Summary of M-Mode, 2D, and
Doppler Echo Features for
Acquired and Congenital Cardiac
Lesions
9 A.M.-5:30 P.M. — Nassau Inn,
Princeton
(Practical Diagnostic Ultrasound
Seminars and AMNJ)
June
6 Preventive Cardiology Seminar
20 1 2 noon- 1 P.M. — NJ Medical School,
Newark
(UMDNJ)
6 Vascular Conference
13 4-5 P.M. — NJ Medical School,
20 Newark
27 (UMDNJ)
6 Cardiac Arrhythmias
I -2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
MEDICINE
May
1 Strokes, C.V.A.— Post and Rehab
Care
I I A.M.-12 noon— Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
2 Medical Grand Rounds
1 1:30 A.M. — VA Medical Center,
East Orange
(Endocrinology Section, AMNJ)
2 Alcoholism
1:30 P.M. —Essex County Hospital
Center, Cedar Grove
(AMNJ)
2 William P. Burpeau Award Dinner
and Memorial Lecture
6:30 P.M. —The Manor, West Orange
(Urology Section, AMNJ)
2 Occupational Medicine for the
Primary Physician
30 Cancer Emergencies
1 :30-2:30 P.M. — Rutgers
Community Health Plan, 57 U.S.
Hwy. **\, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
2 Endocrine Conferences
9 3:30-5 P.M. — Rotates between
16 Newark Beth Israel Medical Ctr.,
23 University Hospital, Newark, and
30 United Hospitals Medical Ctr.,
Newark, and VA Medical Ctr., East
Orange
(Endocrinology Section, AMNJ)
2 Rehabilitation Medicine
9 4: 1 5-5: 1 5 P.M. — Kessler Institute,
16 West Orange
23 (UMDNJ)
30
3 Digestive Disease I
10 8-9 A.M. — NJ Medical School,
17 Newark
24 (UMDNJ)
31
3 Allergy, Immunology Lecture
10 1 1 A.M.-12 noon — Children's
17 Hospital, Newark
24 (UMDNJ)
31
3 Fever of Unknown Origin in the
1980s
24 Carcinoma of the Colon
1 1 A.M. — St. Joseph’s Hospital and
Medical Center. Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
3 Recurrent Abdominal Pain
9 A.M. — Freehold Area Hospital
(AMNJ)
3 Medical Grand Rounds
9:30 A.M. —Newark Beth Israel
Medical Ctr.
(Endocrinology Section, AMNJ)
3 Chemotherapy
4-6 P.M.— Institute for Medical
Research, Copewood Street,
Camden
(Institute Jor Medical Research and
AMNJ)
3- 21 8th Annual Meeting
6 Resorts International, Atlantic City
(Medical Society oj New Jersey
and AMNJ)
4 Medical Grand Rounds
1 1:30 A.M. — University Hospital,
Newark
(Endocrinology Section, AMNJ)
4 Renal Conferences in Nephrology
18 4-5 P.M. — UMDNJ-University
Hospital, Newark
(Nephrology Society oJNJ and
Nephrology Section, AMA)
4 Dept, of Medicine Grand Rounds
11 1 1 :30 A.M.- 1 P.M.— NJ Medical
18 School, Newark
25 (UMDNJ)
4 Grand Rounds in Rehabilitation
1:30-2:30 P.M. —Rotates between
University Hospital, Newark,
Kessler Institute, West Orange, and
Children’s Specialized Hospital,
Westfield
(UMDNJ)
4 Urology Grand Rounds
1 1 3-5 P.M. — NJ Medical School,
18 Newark
25 (UMDNJ)
VOL. 81— NUMBER 4— APRIL 1984
337
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3:30 Coronary Artery Surgery for Patients with Single, Double, and Triple Coronary
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4:00 Coronary Artery Vasoconstriction: Etiology Assessment and Management/
Charles E. Bemis, M.D.
4:30 Rehabilitation of the Patient After Coronary Bypass/David T. Lowenthal, M.D.
5:00 The Management of Patients with Recurrent Angina After Coronary Bypass
Operation/Morris N. Kotler, M.D.
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338
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
8
9
15
15
15
15
29
15
16
16
16
16
23
17
18
19
30
30
VOL.
Principles of Hyperalimentation
in Trauma Patients
7-9 A.M.— Hackensack Medical
Center
( Hackensack Medical Center and
AMNJ )
Glycosylated Hemoglobin and
Home Glucose Monitoring
1 -2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
Newer Concepts in CPR
12:00 noon — St. Mary’s Hospital,
Orange
(AMNJ)
Drugs and Water Metabolism
4- 5 P.M. — Academic Health Science
Ctr., Rm. 393, New Brunswick
(UMDNJ and AMNJ)
Renal Hormone Resistant States
7-8 P.M. — Ramada Inn, Clark
(Nephrology Society of NJ and
AMNJ)
AIDS /Herpes
Clinical Treatment of Headache
1 1 A.M. 1 2 noon — Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
IVP Conference
5- 7 P.M. — East Orange VA Hospital
(UMDNJ)
Interhospital Rheumatology
Rounds
4:30-6 P.M. — University Hospital,
Newark
(UMDNJ)
Drugs, Alcohol, and Pregnant
Women
8:30 A M. -3: 1 5 P.M. — Monmouth
Medical Ctr., Long Branch
(Div. of Alcoholism, NJ State Dept,
of Health, and AMNJ)
Dermatological Conferences
6- 9 P.M. — Rutgers Community
Health Plan, 57 U.S. Hwy. ** 1 , New
Brunswick
(UMDNJ -Rutgers Medical School
and AMNJ)
Modem Medical Genetics
Diseases of Mucous Membrane
10:30-12 noon — St. Mary's
Hospital, Passaic
(St. Mary's Hospital and AMNJ)
Newer Concepts in Sarcoidosis
5-6:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
Clinical Concerns in
Hemodialysis Patients
8: 1 5 A.M.-5 P.M.
8A.M.-1 P.M.— New York Hilton
Hotel, New York City
(Nephrology Society of NJ and
AMNJ)
Gastrointestinal Bleeding
10:30 A.M.- 1 2 noon — St. Mary’s
I lospital. Passaic
(AMNJ)
Hepatic Metabolic Complications
of Alcoholism
1 -2:30 P.M. — VA Medical Ct r., Lyons
Bldg. 93
(VA Medical Ctr. arid AMNJ)
3 1 How To Live To Be 1 00
1 1 A.M. — St. Joseph’s Hospital and
Medical Center, Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
June
1 Urology Grand Rounds
8 3-5 P.M.— NJ Medical School,
15 Newark
22 (UMDNJ)
29
1 Renal Conferences in Nephrology
15 4-5 P.M. — University Hospital,
Newark
(Nephrology Society ofNJ and
Nephrology Section, AMNJ)
1 Grand Rounds in Rehabilitation
1 :30-2:30 P.M. — Rotates between
University Hospital, Newark,
Kessler Institute, West Orange, and
Children's Specialized I lospital,
Westfield
(UMDNJ)
1 Dept, of Medicine Grand Rounds
8 1 1 :30 A.M .- 1 P.M. — NJ Medical
15 School, Newark
22 (UMDNJ)
29
6 Endocrine Conferences
13 3:30-5 P.M. — Rotates between
20 Newark Beth Israel Medical
27 Center, University Hospital,
Newark, and United Hospitals
Medical Ctr., Newark, and VA
Medical Center, E. Orange
(Endocrinology Section, AMNJ)
6 Rehabilitation Medicine
13 4: 1 5-5: 1 5 P.M. —Kessler Institute,
20 West Orange
27 (UMDNJ)
6 Medical Grand Rounds
1 1 :30 A.M. — VA Medical Ct r„ East
Orange
(Endocrinology Section, AMNJ)
6 Gastrointestinal Bleeding
1:30-2:30 P.M. — Essex County
Hospital, Cedar Grove
(Essex County Hospital and AMNJ)
6 Therapeutic Controversies in GI
Diseases
1:30-5 P.M. — Saint Barnabas
Medical Ctr.. Livingston
(NJ Gastroenterological Society
and AMNJ)
6 Common Allergy Problems
20 Inflammatory Bowel Disease
1 :30-2:30 P.M. — Rutgers
Community Health Plan, 57 U.S.
Hwy. 1 . New Brunswick
(Rutgers Community Health Plan
and AMNJ)
7 Digestive Disease I
14 8-9 A.M. — NJ Medical School,
21 Newark
28 (UMDNJ)
7 Digestive Diseases II
14 9- 10 A.M. — NJ Medical School,
21 Newark
28 (UMDNJ)
7 Allergy, Immunology Lecture
14 1 1 A.M 12 noon — Children’s
21 Hospital, Newark
28 (UMDNJ)
7 Management of Short Stature
9 A.M. — Freehold Area Hospital
(AMNJ)
7 Medical Grand Rounds
9:30 A.M. —Newark Beth Israel
Medical Center
(Endocrinology Section, AMNJ)
7 Irritable Bowel Syndrome
1 1 A.M. — St. Joseph's Hospital and
Medical Center, Paterson
(St. Joseph's Hospital and Medical
Center and AMNJ)
8 Medical Grand Rounds
1 1:30 A.M. — UMDNJ-University
Hospital, Newark
(Endocrinology Section, AMNJ)
12 Fluid and Electrolyte Imbalance
1 1 A.M. 12 noon— Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
14 Rheumatology Update
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
19 Continuous Arteriovenous
Hemofiltration
4- 5 P.M — Academic Health Science
Center, New Brunswick
(UMDNJ and AMNJ)
19 IVP Conference
5- 7 P.M. — East Orange VA Hospital
(UMDNJ)
20 Interhospital Rheumatology
Rounds
4:30-6 P.M. — University Hospital,
Newark
(UMDNJ)
20 Pathogenesis, Diagnosis, and
Management of Type II Diabetes
1 -2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
20 Dermatological Conference
6- 9 P.M. — Rutgers Community
Health Plan, 57 U.S. Hwy. 1 , New
Brunswick
(UMDNJ and AMNJ)
20 Cancer of the Colon
27 Diabetes Mellitus
10:30-12 noon — St. Mary's
Hospital, Passaic
(St. Mary's Hospital and AMNJ)
NEUROLOGY/ PSYCHIATRY
May
2 Epilepsy — Classification and New
Treatment
1 0:30 A.M. 1 2 noon — St. Mary's
Hospital, Passaic
(AMNJ)
2 Group Therapy
16 2-3 P.M, — Aneora Psychiatric
30 Hospital
(Aneora Psychiatric Hospital and
AMNJ)
2 Grand Rounds in Psychiatry
1 0:30 A.M - 1 2 noon — NJ Medical
School, Newark
(UMDNJ)
3 The Hypochondriacal Patient
10 Adolescents and Families with
Drug and Alcohol Problems
1 7 Medication T reatment of Phobias
3 1 ECT : Sine v Pulse Wave and Other
New Developments
81— NUMBER 4 — APRIL 1984
339
12 noon 1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
4 Psychiatric Lecture Series
1 1 1 :30-5 P.M —Trenton Psychiatric
18 Hospital
25 (Trenton Psychiatric Hospital and
AMNJ)
7 Effect of Porno Pictures on Sexual
Compulsion of a 5-Year-Old Child
8:15-10:30 P.M. —9 Marquette Road,
Montclair
(Essex Psychiatric Seminar and
AMNJ)
7 Psychotherapies
14 1 -3 P.M.— Ancora Psychiatric
21 Hospital
28 (Ancora Psychiatric Hospital and
AMNJ)
9 Convulsive Seizures
1 -2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital andAMNJ)
1 5 Adolescent Health and Illness
16 9 A.M. -5:00 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
16 Lecture in Psychiatry
1 0:30 A.M 1 2 noon— NJ Medical
School, Newark
(UMDNJ)
16 Psychiatry Lecture
1 -2:30 P.M. —Essex County Hospital
Center, Cedar Grove
(UMDNJ)
1 7 Aspects of Manic - Depressive
Illness
8-10 p.M. —Hackensack Medical
Ctr.
(NJ Psychoanalytic Society and
AMNJ)
2 1 Principles of Child Psychotherapy
8:30-10:30 P.M — 301 Broad St„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
22 Family Therapies
1-3 P.M. —Ancora Psychiatric
Hospital
(Ancora Psychiatric Hospital and
AMNJ)
23 Alarming Growth of Teen-age
Suicides
All day — Holiday Inn, North
Brunswick
(NJ Department of Health and NJ
Public Health Assn.)
June
1 Psychiatric Lecture Series
8 1 :30-5 P.M — Trenton Psychiatric
15 Hospital
(Trenton Psychiatric Hospital and
AMNJ)
4 Depression in a Patient
8: 1 5- 1 0:30 P.M.— 1 046 So. Orange
Ave., Short Hills
(Essex Psychiatric Seminar and
AMNJ)
4 Psychotherapies
1 1 Psychotherapies
25 Behavior Modification
1-3 P.M. — Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
6 Grand Rounds in Psychiatry
10:30 A.M.- 12 noon— NJ Medical
School, Newark
(UMDNJ)
6 Psychoneuroimmunology
9:30 A M. -5 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
6 Group Therapy
2-3 P.M. —Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
7 Calcium Channel Blockers in the
Brain
2 1 Adolescents and Families with
Drug and Alcohol Problems
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
9 Problem Behaviors in
Adolescence
8 A.M. -3:30 P.M — NJ Medical
School, Newark
(UMDNJ. NJ Council oj Child and
Adolescent Psychiatry. andAMNJ)
1 8 Principles of Child Psychotherapy
8:30- 10:30 P.M.— 301 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
20 Lecture in Psychiatry
1 0:30 A M - 1 2 noon— NJ Medical
School, Newark
(UMDNJ)
20 Psychiatry Lecture
1 -2:30 P.M. —Essex County Hospital
Center, Cedar Grove
(UMDNJ)
2 1 Update of Clinical Psychiatry
1 2 noon-4:30 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation andAMNJ)
2 1 The Many Faces of Clinical
Depression
5-6:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
OBSTETRICS/GYNECOLOGY
May
2 Ob/Gyn Lecture
7-8 P.M. — L' Affair Restaurant,
Mountainside
(UMDNJ)
PATHOLOGY
May
9 Pathology Grand Rounds
10:30-12 noon— St. Mary’s
Hospital, Passaic
(St. Mary's Hospital andAMNJ)
10 Pathology Seminars
24 1 2 noon- 1 P.M.— NJ Medical School,
Newark
(UMDNJ)
June
1 3 Pathology Grand Rounds
10:30-12 noon— St. Mary's
Hospital, Passaic
(St. Mary's Hospital andAMNJ)
14 Pathology Seminar
1 2 noon- 1 P.M.— NJ Medical School,
Newark
(UMDNJ)
PEDIATRICS
May
4 Advances in Pediatrics
1 1 9:30- 1 0:30 A.M.— NJ Medical
School,
18 Newark
25 (UMDNJ)
10 Pediatric Malignant Diseases
4-6 P.M. —Institute for Medical
Research, Copewood Street,
Camden
(Institute for Medical Research and
AMNJ)
1 8 Changing Concepts in the
Treatment of Seizures
8-9:30 A.M.— Overlook Hospital,
Summit
(Overlook Hospital andAMNJ)
2 1 Outcome of High-Risk Infants
1 2 noon- 1 P.M.—' The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
June
1 Advances in Pediatrics
8 9:30-10:30 A.M.— NJ Medical
School,
15 Newark
22 (UMDNJ)
29
8 AIDS in Children
8-9:30 A.M. —Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
1 8 Practical Aspects of Pediatric
Toxicology
12 noon- 1 P.M.— The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
RADIOLOGY
May
9 Radiology Grand Rounds
23 2-4 P.M. —University Hospital,
Newark
(UMDNJ)
16 Dinner Meeting
6:30 P.M. —The Manor, West Orange
(Radiotherapy Section, AMNJ)
17 Combined Meeting
7:30- 1 0 p.M.— Saint Barnabas
Medical Ctr., Livingston
(NJ Institute of Ultrasound,
Radiological Society ofNJ, and
Diagnostic Radiology Section,
AMNJ)
23 CT Conference
4-6 P.M. —University Hospital,
Newark
(UMDNJ)
24 Forensic Radiology
1:30-5 P.M. —Saint Barnabas
Medical Ctr., Livingston
(Saint Barnabas Medical Ctr. and
AMNJ)
June
6 Radiology Grand Rounds
20 2-4 P.M. — University Hospital,
340
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Newark
( UMDNJ )
27 CT Conference
4-6 P.M.— University Hospital,
Newark
(UMDNJ)
SURGERY
May
2 Surgical Departmental
9 Conferences
16 8:30- 10 A.M. — Rutgers Medical
23 School, Medical Education Bldg.,
30 New Brunswick
(UMDNJ and AMNJ)
5 Surgical Morbidity and Mortality
12 Conference
19 8:30-10 A.M.—NJ Medical School,
26 Newark
(UMDNJ)
7 Surgical Grand Rounds/Lecture
14 Series
21 4:30-5:30 P.M. — NJ Medical School.
Newark
(UMDNJ)
16 Common Outpatient Surgical
Problems
1:30-2:30 P.M. — Community Health
Plan, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
30 Surgical Nutrition
1-2:30 P.M. —Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
June
2 Surgical Morbidity and Mortality
9 Conference
16 8:30-10 A.M. — NJ Medical School,
23 Newark
30 (UMNDJ)
4 Surgical Grand Rounds/Lecture
1 1 Series
18 4:30-5:30 P.M. — NJ Medical School,
25 Newark
(UMDNJ)
6 Surgical Departmental
13 Conference
20 8:30-10 A.M.— Rutgers Medical
School, Medical Education Bldg.,
New Brunswick
(UMDNJ and AMNJ)
SURGICAL SPECIALTIES
May
2 Management of Lacrimal Drainage
Problems
7:30-9:30 P.M. —Saint Barnabas
Medical Ctr., Livingston
(AMNJ)
3 Vascular Surgical Rounds
10 4-5 P.M. —Rutgers Medical School,
17 Medical Education Bldg., New
24 Brunswick
3 1 (UMDNJ a nd AMNJ)
4 Cancer Research Colloquium
11 12 noon- 1 P.M. —University
18 Hospital, Newark
25 (UMDNJ)
5 Surgical Treatment of
Cardiothoracic Diseases
10-1 1:30 A.M.—NJ Medical School,
Newark
(UMDNJ)
7 Tumor Conference
14 8-9 A.M.— University Hospital,
21 Newark
(UMDNJ)
1 6 Eye Institute Grand Rounds
7-9 P.M. —United Hospital Annex
Bldg., Newark
(UMDNJ)
1 7 Neurosurgery Lecture
4-5 P.M. — University Hospital,
Newark
(UMDNJ)
June
1 Cancer Research Colloquium
18 12 noon-1 P.M. — University
Hospital
15 F467
22 (UMDNJ)
29
2 Surgical Treatment of
Cardiothoracic Diseases
10-11 :30 A M. — NJ Medical School,
Newark
(UMDNJ)
4 Tumor Conference
11 8-9 A.M. — University Hospital,
18 Newark
25 (UMDNJ)
7 Vascular Surgical Rounds
14 4-5 P.M. — Rutgers Medical School,
21 Medical Education Bldg., New
28 Brunswick
(UMDNJ and AMNJ)
1 9 Surgical Treatment of Morbid
Obesity
12 noon— St. Maiy’s Hospital,
Orange
(AMNJ)
20 Eye Institute Grand Rounds
7-9 P.M. —United Hospital Annex
Bldg.
(UMDNJ)
2 1 Neurosurgery Lecture
4-5 P.M. — University Hospital,
Newark
(UMDNJ)
MISCELLANEOUS
May
1 Computers in Medicine
7:30 P.M. —Burdette Tomlin
Mem. Hosp., Cape May Court House
(AMNJ)
1 0 Patient Advocacy Issues Two
Years Later
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
VOL. 81— NUMBER 4— APRIL 1984
341
Letters to the
Editor
Presidential Column;
Dr. Harrison Martland;
Reorganization of Hospital
Staffing; The Law of the
Duck
Presidential Column
December 30, 1983
Dear Doctor Krosnick:
After reading Dr. Kovacs's presi-
dential column in the December
issue of The Journal, MSNJ, I had
feelings of uncertainty.
The situations he outlined were
those we have read and reread in the
AMA News and the various printed
media confronting us t.i.d.
In ending his essay. Dr. Kovacs
states that time is running out on
our “having an opportunity to be-
come an active participant in the
newly evolving practices of medi-
cine" else we become a "fully regu-
lated and controlled public utility."
In the last paragraph, he reminds
us that “our position is (not) a weak
one" and that we "can still effect
benefical change if we unite for that
purpose."
Early on. Dr. Kovacs actively em-
braced participation in a local I1MO-
IPA. This form of organization is
thought by many physicians to be
adverse to the best interests of both
patient and doctor in the context of
independent private practice.
Before we energetically unite
under Dr. Kovacs’s leadership, I
hope he will devote his next column
to letting us know specifically to
which programs and changes he
would commit us.
(signed) Albert Minzter, M.D.
Dr. Harrison Martland
January 19, 1984
Dear Doctor Krosnick:
The cover photograph on the
January 1984 issue of The Journal
is incredibly insensitive, tasteless,
and ironic.
As physicians, the implicit ap-
proval of smoking in the photograph
at a time when we know the effects
on heart disease and cancer is ap-
palling.
The insensitivity of the cigarette
ashes dangling and about to fall on
the remains of a cadaver is obvious.
I am embarrassed for the Society
and the profession.
(signed) James Bellet, M.D.
Editor’s Response: The cover
photograph on the January 1984
issue of The Journal is a picture of
Dr. Harrison Martland, who was ap-
pointed pathologist to Newark City
Hospital in 1908. The photograph
was made available to us from the
Archives of UMDNJ, George F. Smith
Library, in Newark. Those who knew
Dr. Martland have told me that the
cover likeness is absolutely typical of
the very colorful man.
The use of the picture of the scien-
tist whose work was reviewed in the
Medical History article in the same
issue is both logical and fair, in my
opinion.
I disagree that this cover gives
“implicit approval of smoking." I do
not smoke, nor do I allow smoking
in my home or office. In fact, I have
written antismoking articles for The
Journal which may have prodded
the Board to ban smoking at MSNJ
meetings. I appreciate and agree
with your obvious antismoking de-
meanor.
The question of “insensitivity to
the cigarette ashes dangling" must
be overridden by the historical sig-
nificance of the issue. Cigarette
smoking in the first quarter of this
century cannot be condemned in the
light of present day scientific fact. To
accuse the Editor, the Medical So-
ciety, or the Publication Committee
of insensitivity on the issue seems
unfair; that attitude is tantamount
to hurling the same accusation at
the photographers who daily send
back pictures of the antihuman hor-
rors in El Salvador, Lebanon, and
elsewhere in this world and at the
editors of the newspapers, maga-
zines, and television programs
which reproduce them.
History is history and we have no
right to censor or distort it to make
it conform to some other standards
of conduct.
I understand your feelings, but I
do not share them on this issue.
January 26, 1984
Dear Doctor Krosnick
The cover photo on the January
1 984 issue of The Journal is beauti-
ful and fit for framing except there
is no way of removing the mailing
address and leaving a clean surface.
I desire to send covers to Martland’s
daughter and two grandsons.
(signed) Samuel Berg, M.D.
Reorganization of
Hospital Staffing
February 4, 1984
Dear Doctor Krosnick:
A case is coming to the courts
which potentially can change the or-
ganization of hospital staffing.
Marilyn Wrable, a nurse practicing
psychiatric counseling, recently was
asked to see a patient of hers hospi-
talized locally. Hospital rules
provided that a nonstaff member
may be accorded temporary privi-
leges by cojoint agreement between
the president of the medical staff, as
well as the administrator on duty.
The physician agreed, and the ad-
ministrator refused to permit an of-
ficial consultation, but was willing
to allow the nurse-counselor to visit
her patient unofficially. This inci-
dent seeded circumstances which
promise to end in the courts, and
possibly change the manner in
which hospital staffs are organized.
Until recently, hospitals have been
the domain of physicians. If phy-
sicians did not like a hospital, or
conditions were too crowded, or
competition too severe, they might
find another. This circumstance has
been prohibited in New Jersey for a
dozen or so years, since the enact-
ment of the certificate of need.
342
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The state has restricted the
number of allowable hospital beds.
Thus, nonmedical "providers” are
seeking hospital privileges in re-
stricted hospital space. Since the
number of hospitals now is limited
by law, nonmedical providers, some
of whom are licensed under one
board or another to practice their
specialties, will be vying with medi-
cal practitioners for medical beds.
Medical staffs will find themselves
embroiled with chiropractors,
podiatrists, optometrists, physical
therapists, and dietitians for bed
space and consultation privileges, as
these special-interest groups seek
hospital privileges.
Hospital staffs currently are re-
stricted to physicians and, in some
instances, physicians and dentists.
The courts seem prone to permit
or even force the current medical
and medical-dental staffs to provide
space and supervision for
nonmedical specialists.
The professional corporation law
in New Jersey permits the banding
together of members of one pro-
fession to form a professional as-
sociation; but doctors cannot mingle
with dentists, and so forth. The as-
sociation by law is restricted to the
members of one profession only.
Yet, in hospitals, the trend is to
create adjunct staffs for the
nonmedical groups, under the aegis
of the medical staff.
I suggest it would be wiser to fol-
low the precepts of the professional
corporation law. All medical staffs
should incorporate under this law.
This will exclude dentists who can
form their own corporations, as can
other nonmedical specialty groups.
Under the current system, the medi-
cal staffs are expected to supervise
and take responsibility for the
nonmedical adjunct staff members.
This responsibility falls beyond the
limits of our licensure.
Doctors should divorce them-
selves from the other groups, in-
corporate as a professional associa-
tion, join the hospital on that basis;
and then let the hospital decide on
the status it wants to grant op-
tometrists, chiropractors, podi-
atrists, dietitians, and physical
therapists who also want staff privi-
leges. None of these should be mem-
bers of the medical staff because the
medical staff is not competent under
their license to supervise them, and
because the law will not permit mix-
ing of specialties under the pro-
fessional association act.
Failure of doctors to do this will
embroil us continually in litigation,
and empower judges and lawyers
who have never practiced the art of
medicine, to foist upon us respon-
sibilities we neither want nor need.
Our business is medicine; our
license is medicine; and we are not
to be diverted by a struggle for the
hospital turf.
Failing to do this we will find
ourselves, already contributing con-
siderable time to hospital manage-
ment, trying to direct staffs that
have been reshaped by the courts.
Retreat is occasionally timely; and
I would suggest that now is the time
to retreat into the bastion of medi-
cine and let the other armies fight
it out with the hospital adminis-
trations. Then the hospitals (rather
than the doctors) will not only have
to deal with these responsibilities,
but also be responsible for these
dealings.
(signed) Charles Harris, M.D.
The Law of the Duck
February 6, 1984
Dear Doctor Krosnick:
If you talk like a businessman,
think like a businessman, and mar-
ket your wares like a businessman,
then it would be reasonable to con-
clude you are a businessman.
That is— unless you are a doctor.
In this instance you become a
hybrid; to be considered a respon-
sible professional but not to be regu-
lated as a businessman. That is, ac-
cording to the AMA.
Somehow, I find that a bit hard to
swallow and I suspect, so does the
general public. I am afraid that our
medical leaders in Chicago will have
us believe that, unless we get right
out and actively market our medical
products and services in this
“changing competitive environ-
ment," we independent practicing
physicians soon will become an en-
dangered species.
I resent that organized medicine
has chosen to encourage a physician
to conduct his practice of medicine
in business-like jargon and promo-
tional schemes. I resent the fact that
our professional societies them-
selves have accepted the verbal and
mental syntax of an advertising and
marketing agency. I often think that
the AMA is tiying to stampede us, its
membership, into a state of panic in
order to play the role of an in-
dispensible shepherd rescuing his
flock.
For whose benefit is the AMA
spending money to hire a full-time
expert to encourage the practicing
physicians to market their services
in order to increase their business?
I believe that when we think of
ourselves and our work in these
terms we will be assuming the pos-
ition which the Federal Trade Com-
mission wishes us to adopt.
Let us stop this game of words and
images. Let us practice medicine as
best we can, with our patients’ wel-
fare first and foremost. Let us stop
trying to act like tradesmen and, in-
stead, conduct ourselves as phy-
sicians.
(signed) Albert Minzter, M.D.
VOL. 81 -NUMBER 4— APRIL 1984
343
BOOK REVIEWS
Aesthetic Breast Surgery;
Common Skin Disorders;
Diabetes: A New Complete
Guide to Healthier Living;
Disorders of the Hip;
Power and the Profession
of Obstetrics
Aesthetic Breast Surgery
Nicholas G. Georgiade, M.D. Balti-
more, MD, Williams & Wilkins,
1983. Pp. 408. Illustrated.
($69.95)
The preface to this book begins by
quoting Robert Browning: “Beauty
is in the eye of the beholder." Cer-
tainly, no organ is more associated
with femininity than the breast, and
cosmetic and reconstructive surgery
on the breast is performed daily at
hospitals throughout the country.
The editor has assembled an in-
ternational cast of experts to
produce a volume of 30 chapters
that run the gamut from anatomy
and physiology to psychology, but
focus, to a great degree, on augmen-
tation and reduction mammoplasty.
There is a plethora of illustrations
(black and white) which is man-
datory in a book such as this.
(Browning was right!) Each chapter
concludes with a list of suggested
readings. Many of the chapters are
devoted to the same subject, e.g.
breast augmentation, breast reduc-
tion, and the reader can compare
among operative procedures
espoused by experts from through-
out the world.
This is a highly specialized book
which will appeal to plastic sur-
geons, general surgeons, and resi-
dents in surgery. However, as an ad-
dition to a library it would have a
broader audience since so many
physicians deal with women with
breast diseases and might well be
interested in the aesthetic results of
the surgery.
Ralph S. Greco, M.D.
UMDNJ-Rutgers Medical School
Common Skin Disorders ,
2nd Edition
Ernst Epstein, M.D. Oradell, NJ,
Medical Economics Books, 1983.
Pp. 280. Illustrated. ($25.95)
This softcover, large format man-
ual is for the nonspecialist. The
dermatologist-author provides a
simplified, and very personal, view of
what the doctor and the patient
should know about some of the
more common skin problems. The
book is a combination folksy-dis-
cussion and recipe collection, which
explains each condition and its
rational management. The initial
portion of the volume is directed to
the physician, the remaining one-
third consists of tear-out patient in-
struction sheets. These handouts
contain easy-to-understand expla-
nations which repeat what the phy-
sician already should have told the
patient. Here is a palpable reminder
of the encounter, designed to help
the memory or further instruct fam-
ily, friends, and acquaintances. This
emphasis on patient education is
the book's chief attribute.
Dermatological colleagues may
not agree with each of the author’s
explanations or specific treatment
regimens. Nonetheless, the success-
ful therapist will endorse, and prac-
tice, the philosophy which Dr. Ep-
stein illustrates nicely in his teach-
ing.
Christopher M. Papa, M.D.
Diabetes: A New and
Complete Guide to
Healthier Living for
Parents , Children , and
Young Adults Who Have
Insulin-Dependent
Diabetes
Lee Ducat and Sherry Suib Cohn.
New York, NY, Harper &. Row,
1983. Pp. 253. ($13.95)
In recent years, individuals suffer-
ing from the same disease have
banded together for support as well
as to trade experiences and helpful
hints in coping with their illness.
The principal author of this book is
a founder of such a group, stimu-
lated to act when her son was
diagnosed as an insulin-dependent
diabetic. She founded the Juvenile
Diabetes Foundation, whose per-
formance in giving emotional sup-
port, disseminating information,
and funding research has been
outstanding.
This book is neither a cold scien-
tific tome nor a manual of diabetes.
On the contrary, it is a compilation
of information gleaned from the
actual patient and families of those
affected. It is a parent-to-parent, no-
nonsense approach, pulls-no-
punches text— it tells it like it is. The
prose is not elegant; the language is
plain and occasionally crude, but it
fills the gap between the doctor's of-
fice and the problems of everyday liv-
ing with diabetes. Starting from the
moment of shock at being told the
diagnosis, to the later worries about
school, camp, sex, marriage, and the
fear of complications, it answers
questions that plague all families:
I've given my four-year old diabetic
child his insulin, how do I get him
to eat? What is his future? What if
he gets sick with a cold or a
gastrointestinal disturbance? Are
there physical factors as well as emo-
tional factors preventing or inter-
fering with a good marriage? Can
my daughter have a baby? What
about my other children?
This book is eminently practical
and helpful and should be in the
hands of any patient or family with
insulin-dependent diabetes. To the
parent, it will give as much help and
comfort as Dr. Spock's books did in
helping rear nondiabetic children.
To the physician, it will provide a
further understanding of what it is
to live and cope with this disease.
Samuel E. Einhom, M.D.
Disorders of the Hip
David M. Gruebel-Lee. Philadel-
phia, PA, J.B. Lippincott Co.,
1983. Pp. 282. ($49.50)
We have come to expect a certain
elegance of style and clarity of word
in the books we receive from our
British colleagues, and Mr. Gruebel-
Lee does not disappoint us in this
very personal work. With the excep-
tion of a four-page section on the
subject of the doctor-patient rela-
344
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
tionship, contributed by Dr. David
Hirsh of the Albert Einstein College
of Medicine, which includes men-
tion of the uniquely American prob-
lem of malpractice, this is a distinct-
ly British volume.
The author’s preface clearly states
that it was his intention to interest,
challenge, and stimulate his col-
leagues and residents in training,
through his own understanding of
hip disease, as gained from a life-
time’s work. In this, I feel that he has
clearly succeeded.
Each chapter begins with a brief
exposition of what we are to learn,
and the text generally delivers; some-
times it is made untidy by the seem-
ingly random and sometime unex-
pected insertions of case histories.
(Case 4 is accompanied by a set of
x-rays which apparently are those of
another patient!) While the quality
of reproduction of the radiographic
studies is only fair, the many line
drawings superbly illustrate the
anatomical concepts they are meant
to demonstrate. I cannot recall a
clearer demonstration of the con-
cept of femoral anteversion and
retroversion than is found here.
That very Britishness which
makes this volume so readable, does
tend to limit its breadth of view. The
discussion of total hip arthroplasty,
while giving valuable insight into
the development of the procedure
and paying due homage to the late
Sir John Chamley, virtually ignores
current concepts and designs com-
monly used in this country. This
book is not to be any orthopedist’s
basic reference, nor was that the
author’s intent. Nevertheless, it de-
serves a place in the home and office,
first to be kept at the bedside table,
to be savored in its entirety, morsel
by morsel, for its many refreshing
aspects, and then to gain its rightful
place in the library, as the source of
history, information, and con-
troversy which its author intended
it to be.
Robert A. Goldstone, M.D.
Power and the Profession
of Obstetrics
William Ray Amey. Chicago, IL,
The University of Chicago Press,
1983. Pp. 290. ($25)
The author, a sociologist from
Evergreen State College, has
mounted a prodigious effort to ex-
plain the genesis, evolution, and
present status of obstetric practice
in the United States. It is truly a
commendable scholarly achieve-
ment by a nonphysician who has
crammed into less than 300 pages
an amazing amount of factual infor-
mation liberally laced with opinions
from a galaxy of medical and
nonmedical authors.
Although Mr. Amey’s thrust is
not particularly antimale, the con-
cept of "power” that appears in his
title as well as his text implies a male
movement to control yet another
facet of a woman’s anatomic and
social function, particularly his de-
scription of the usurpation of the
midwives’ role. Moreover, his reci-
tation of the events of the past 20
years should have been tempered by
two well-known phenomena to
which he seems to have paid scant
notice; the increasing number of
women who have entered the ranks
of academic and clinical obstetrics
and gynecology, and the increasing
number of malpractice suits with
higher and higher awards. The pub-
lic’s expectation of perfect babies
has been nurtured by the conscien-
tious efforts of modem obstetrics
which tries to anticipate and man-
age every potential pathologic event
and, consequently, occasional un-
satisfactory results serve as grist for
the monster mill of malpractice.
Thus, there is no obstetrician today
who does not look daily upon
himself or herself as a potential de-
fendant before the bar of justice,
thereby influencing the perception
and practice of obstetrics.
Despite the author’s excellent
scholarship, thorough research, and
articulate literaiy style, it still is dif-
ficult to determine for whom this
book should be recommended.
Samuel Johnson once commented
about a dog who strutted about on
his hind legs; it is not a question of
how well he does it but rather why
is he doing it at all.
Jerome Abrams, M.D.
VOL. 81— NUMBER 4— APRIL 1984
345
Obituaries
Dr. John H. BonneUy
John Henry Donnelly, M.D., died
on January 24, 1984. Bom in 1910,
Dr. Donnelly earned his medical
degree at Jefferson Medical College,
Pennsylvania in 1937. A retired
member of our Essex County com-
ponent, Dr. Donnelly was a
cardiologist with offices in Newark
and East Orange; he was affiliated
with St. Mary’s Hospital, Orange,
and St. Vincent’s Hospital, Mont-
clair. Dr. Donnelly was a Diplomate
of the American Board of Cardio-
vascular Disease, a member of the
American Medical Association, and
a Fellow of the American Heart As-
sociation.
Dr. H.C. Essertier
Harland Crandall Essertier, M.D.,
former chief of The Valley Hospital,
Ridgewood, died on January 14,
1984. A family practitioner, Dr. Es-
sertier was bom in 1915 and re-
ceived his medical degree from the
University of Pennsylvania School of
Medicine in 1940. A member of our
Bergen County component and of
the American Medical Association,
Dr. Essertier also was affiliated with
Hackensack Medical Center and
Bergen Pines County Hospital, Para-
mus.
Dr, M.J. Frantantuno
At the age of 73, Michael Joseph
Frantantuno, M.D., died on January
24, 1984. In 1935, Dr. Frantantuno
graduated from Marquette Univer-
sity Medical School, Wisconsin. A
member of our Essex County com-
ponent, Dr. Frantantuno was the
health officer for the city of Newark.
During his career he was affiliated
with Clara Maass Medical Center,
Belleville, and Saint Michael’s Medi-
cal Center, Newark. He was a mem-
ber of the American Medical As-
sociation.
Dr. Donald K. Gilbert
On January 12, 1984, Donald King
Gilbert, M.D., died. Bom in 1933, Dr.
Gilbert earned his medical degree at
the University of Pennsylvania
School of Medicine in 1959. During
his career as an internist. Dr. Gilbert
was affiliated with Saint Barnabas
Medical Center, Livingston. He was
a member of our Essex County com-
ponent and a Diplomate of the
American Board of Internal Medi-
cine.
Dr. Oram R. Kline
Word has been received of the
death of Oram R Kline, M.D., last
year. Dr. Kline, a retired member of
our Camden County component,
was bom in 1891 and received his
medical degree from Jefferson Medi-
cal College in 1917. During his
lengthy career, Dr. Kline was af-
filiated with Cooper Medical Center,
Camden, Underwood-Memorial Hos-
pital, Woodbury, and Burlington
County Memorial Hospital, Mount
Holly. Dr. Kline was a member of the
American Medical Association and a
Fellow of the American College of
Surgeons.
Dr. Adolph H. Koralek
Adolph Hugo Koralek, M.D., died
on December 26, 1 983, at the age of
70. Dr. Koralek earned his medical
degree at the University of Prague,
Czechoslovakia, in 1938. Dr. Koralek
was a member of our Essex County
component and of the American
Medical Association; during his ca-
reer, Dr. Koralek was affiliated with
Clara Maass Medical Center,
Belleville, Saint Barnabas Medical
Center, Livingston, and Saint James
Hospital, Newark. A family practi-
tioner, Dr. Koralek was a consulting
physician for U.S. Steel Co., Newark,
for 20 years.
Dr. Hilton S. Read
At the grand age of 84, Hilton
Shreve Read, M.D., a retired member
of our Atlantic County component,
died on January 5, 1984. Dr. Read
graduated from Jefferson Medical
College in 1923 and during his ca-
reer was affiliated with Atlantic City
Medical Center. He was a member of
the American Medical Association, a
Diplomate of the American Board of
Internal Medicine, and a Fellow of
the American College of Physicians.
Dr. Read retired to Thomasville,
Georgia.
Dr. Steven F. Stein
At the untimely age of 42, Steven
F. Stein, M.D., died on December 22,
1983, in an automobile accident. Dr.
Stein earned his medical degree at
Downstate Medical Center, New
York, in 1965. A urologist. Dr. Stein
was affiliated with Riverview Hospi-
tal, Red Bank, Bayshore Community
Hospital, Holmdel, and Monmouth
Medical Center, Long Branch. Dr.
Stein was a member of our Mon-
mouth County component and of
the American Medical Association
and was a Fellow of the American
College of Surgeons. Dr. Stein also
was a Diplomate of the American
Board of Urology. He practiced pri-
vately in Long Branch and Hazlet.
346
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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VOL. 81— NUMBER 4— APRIL 1984
347
SEEKING
RADIOLOGY OFFICE PRACTICE
A Board Certified Radiologist with nine years hospital
based experience is seeking to buy into or buy out an
active private office radiology practice in Northern or
Central New Jersey.
Write: Box No. 71 JMSNJ
Two Princess Road
Lawrenceville, NJ 08648
PHYSICIANS
Private health and social research organization is seeking
Physicians for a health and nutrition examination survey spon-
sored by the U.S. Public Health Service. Physicians will con-
duct physical examinations using government supplied mobile
examination centers in selected areas of the New York Metro-
politan area.
Candidates MUST be bilingual in Spanish/English, licensed
in at least one state and meet EXTENSIVE travel requirements.
Doctors must be board eligible or certified in Family Practice,
Internal Medicine or Preventive Medicine.
Competitive salaries, per diem and travel allowances. Send
resume to: Westat, Inc., Attn: Personnel Dept. PM 84, 1650
Research Blvd., Rockville, MD 20850.
GROUP PRACTICE
OPPORTUNITIES
BC/BE Family Practitioners for expanding
federally qualified HMO, serving 36,000
members from three delivery sites in Cos-
mopolitan South Jersey area. Congenial
staff of 30 full-time physicians, and 75 to 100
contracting specialists covering all dis-
ciplines. Excellent hospital facilities. Medical
school affiliation. Choice of pleasant living
conditions in suburban, rural, or semi-rural
communities. Superior schools. Easy access
to Philadelphia (15 minutes), New York City
(90 minutes), Jersey Shore (60 minutes),
Jersey Pine Barrens (20 minutes) and
Pocono Recreation Area (2 hours). Com-
petitive salary and comprehensive benefit
package.
Send Curriculum Vitae to Kenneth M.
Carroll, M.D., Executive Vice Presi-
dent/Medical Affairs, Health Care Plan of
New Jersey, 165 Old Marlton Pike, Medford,
New Jersey 08055.
PHYSICIAN
HOUSE PHYSICIAN/
MEDICAL OFFICER
Our progressive acute care JCHH accredited
community hospital is seeking an Intensivist, 1
or 2 years training in critical care medicine,
post internal medicine residency. Full responsi-
bility for handling all critical care and trauma
situations in the hospital. Board Certified or
admissibility preferred. This position has a
potential for future development of private
practices in several sub-specialities. Our well
managed hospital is located in a desirable
community in southern New Jersey easily corn-
mutable to Philadelphia, Atlantic City, Trenton,
and Wilmington. We offer a competitive salary
and liberal fringe benefits. Send resume to:
James J. Duncan
Vice President for Human Resources
NEWCOMB HOSPITAL
65 S. State St.
Vineland, NJ 08360
an equal opportunity employer
A — fc
UNIVERSITY PHYSICIANS
j STUDENT HEALTH PROGRAM
Responsible for providing primary care to student and dependent
population. Requires experience in adolescent and young adult
medicine, including athletic medicine, office gynecology and man-
agement of emotionally-related medical problems. Strong clinical
skills and ability to administer a student health clinical program
desirable. Candidate should be Board Certified or eligible in
Internal Medicine, Pediatrics or Family Practice Medicine. Position
will require some evening and weekend responsibilities including
inpatient rounds. Salary and benefits competitive for college health
field. The Isabella McCosh Health Center is AAAHC accredited with
a staff of six full-time physicians.
EMPLOYEE HEALTH PROGRAM
Responsible for EMPLOYEE HEATH PROGRAM, including super-
vision of supporting staff, primary care of work-related injuries and
illnesses, evaluation of compensation cases, and liaison with Uni-
versity departments. Position also includes some clinical
responsibilities in student health care. Candidate should be Board
Certified or eligible in Internal Medicine. Experience in employee
health care and demonstrated administrative ability required. Ex-
perience in adolescent and young adult medicine highly desirable.
| Some evening and weekend responsibilities including inpatient
rounds. Salary and benefits competitive for college health field. The
Isabella McCosh Health Center is AAAHC accredited. Facilities in-
clude: an ambulatory care service, 21 -bed inpatient service, x-ray i,:
and laboratory, counseling center, pharmacy services, health
i education, athletic medicine, physical therapy, and a Department
of Occupational Health and Safety.
Forward C.V. and three current references to:
L.A. PYLE, Jr., M.D.
Director, University Health Services
c/o PERSONNEL SERVICES, CLIO HALL-MSN
PRINCETON UNIVERSITY
PRINCETON, NEW JERSEY 08544
PRINCETON UNIVERSITY
An Equal Opportunity/Affirmative Action Employer M/F
348
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Need A Temporary Physician?
CompHealth treats your practice as if it were our
own during: vacations, CMEs, recruiting, clinic
start-up or other absences.
Want Free Time While You
Practice Medicine?
Join CompHealth’s Locum Tenens Physician Group.
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For further information about temporary coverage
or locum tenens practice opportunities, call:
ua CompHealth
A Physician Group
WILSON ROSS, Regional Administrator
114 Centennial Avenue
Sewickley, PA 15143
Telephone: 412/741-3310
To Career Oriented Em
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Wanted: Physicians who prefer
medicine to paperwork.
We are looking for dedicated physicians, phy-
sicians who want to be, not salesmen, accoun-
tants, and lawyers, but physicians. For such
physicians, we offer a practice that is practically
perfect, where in almost no time you experience
a spectrum of cases some physicians do not en-
counter in a lifetime, where you work without wor-
rying whether the patient can pay or you will be
paid, and where you prescribe, not the least care,
nor the most defensive care, but the best care.
If that is what you want, join the physicians who
have joined the Army. Army Medicine is the per-
fect setting for the dedicated physician. Army
Medicine provides wide-ranging opportunities for
the student, the resident, and the practicing phy-
sician alike.
Army Medicine offers fully accredited resi-
dencies in virtually every specialty. Army resi-
dents generally receive higher compensation and
greater responsibility than do their civilian
counterparts and score higher on specialty exam-
inations.
Army Medicine offers an attractive alternative to
civilian practice. As an Army Officer, you receive
substantial compensation, extensive annual paid
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freedom to practice without endless insurance
forms, malpractice premiums, and cash flow
worries.
Army Medicine:
The practice that’s practically all medicine.
FOR FURTHER INFORMATION CALL COLLECT:
1LT John J. Schafer, AMEDD Personnel Counselor, USA MEDDAC,
Fort Dix, NJ 08640 Phone: (609) 562-4271
An Equal Opportunity Employer
VOL. 81— NUMBER 4— APRIL 1984
349
CLASSIFIED ADVERTISEMENTS
DIAGNOSTIC RADIOLOGIST— Board
certified, trained in general diagnosis,
nuclear medicine, special procedures,
C.T. and ultrasound. Available full or
part-time; group practice or hospital
based; North or Central NJ. Can also
provide mobile ultrasound and office
consultation. Reply Box No. 63, JMSNJ.
ENDOCRINOLOGIST-INTERNIST— 34,
Board certified in internal medicine and
in endocrinology ( 1979). Desires partner-
ship or group practice in Northeast NJ,
NYC or vicinity. Experience includes
major teaching university and private
practice. Available immediately. Reply
Box No. 74, JMSNJ.
FAMILY PRACTICE RESIDENT— New
Jersey born, available July 1984.
Interested in joining group practice or
existing Family Practice. Write Box No.
72, JMSNJ.
GENERAL PRACTITIONER— Desires in
dustrial, pharmaceutical or similar posi-
tion. Semi-retired, age 55, 201-545-
4339.
GENERAL SURGEON— Board certified,
wishes to join another surgeon or a
group in area of Monmouth County or
adjoining counties. If interested please
contact Dr. Hasan 201-972-1584.
INTERNAL MEDICINE— Board eligible,
general internist with extensive emer-
gency room experience. Seeking group
practice of internal medicine or emer-
gency room position. Northern NJ area.
Available July 1984. Please call
212-645-4616, Steven Wolinsky, M.D.
Curriculum vitae and references avail-
able upon request.
INTERNAL MEDICINE— Seeking small
group practice IV2 hours from NYC, CT,
NJ. Boston and NYC University hospital
trained internist. Boston University MD
Cum Laude. 1981. ABIM eligible and
available July 1984. Contact Box No. 70,
JMSNJ.
OB/GYN— Board certified, 35, experi-
enced. Wants to relocate. Solo, group or
partnership. Available immediately.
Write Box No. 66, MSNJ.
OPHTHALMOLOGIST— Board eligible,
July 1984. Board certified Pediatrics
(1982), age 29, desires partnership or
group. Available July 1984. Write Box No.
65, JMSNJ.
PHYSICIAN — Retired MD, age 60, seeks
part or full time job in South Jersey.
Prefer institutional, outpatient or in-
surance work. Telephone 609-927-7782
or 609-927-1873.
PHYSICIANS — Registered Dietitian
available to provide nutritional counsel-
ing for your patients at your office or
mine. Trenton - Princeton - New Bruns-
wick area Call 609-737-2160.
PEDIATRICIAN— Middle-age, board
certified, planning to sell private practice.
Seeks part-time position, Pediatric clinic
or office. Prefer Monmouth or Ocean
County. Willing to work nights and week-
ends. Write Box No. 73, JMSNJ.
NEEDED CARDIOLOGIST/INTERNIST
Cardiologist needed for multi-specialty
Internal Medicine group in the South
Jersey area near Atlantic City. Salary
with eventual partnership. Excellent
benefit package. If interested please send
curriculum vitae to Box No. 76, JMSNJ.
NEEDED FAMILY PHYSICIAN— Board
eligible, for partnership in one of the
largest family practice facilities in New
Jersey. Please send resume to Box No. 69,
JMSNJ.
NEEDED PEDIATRICIAN— A well estab-
lished pediatric office in Southern New
Jersey seeks a pediatrician-generalist or
subspecialist as an Associate. Write Box
No. 75, JMSNJ.
NEEDED ASSOCIATE— Board certified
Pediatrician seeks board certified/
eligible associate to join well established
practice. Excellent opportunity, Northern
NJ near NYC. Write Box No. 40, JMSNJ.
NEEDED PHYSICIANS— For successful,
well-known, walk-in medical office
center. Central NJ. Full time and part
time, skilled and personable American
trained MD’s. Send CV to Medemerge,
1005 N. Washington Ave„ Greenbrook,
NJ 08812.
NEEDED PRIMARY CARE PHYSICIANS
Private fee-for service practice in new,
fully equipped suburban offices. All per-
sonal supplies and management services
provided. This is an excellent opportuni-
ty for physicians with a good "bedside"
manner interested in developing a lucra-
tive practice and still desiring time for
the pursuit of happiness. Reply to Neigh-
borhood Doctor Corporation, 901 Long
Beach Blvd., Ship Bottom, NJ 08008.
ALLERGY PRACTICE— Allergist
certified or board eligible for Purchase of
very desirable Practice, child and adult.
Central, NJ. Write Box No. 47, JMSNJ.
RADIOLOGY OFFICE PRACTICE
WANTED — Board certified Radiologist
with nine years hospital based ex-
perience is seeking to buy into or buy out
an active private office radiology practice
in northern or central NJ. Write Box No.
71. JMSNJ.
EQUIPMENT — For Sale Irex System II M-
Mode echocardiogram, mint condition, 2
years old, asking $10,000.00. Will accept
terms. Call 201-748-6101.
EQUIPMENT— Pulmonary equipment
and office space for lease in Trenton, NJ.
Vicinity in Medical Arts Bldg with radio-
logy, internal medicine, laboratory and
cardiology. Excellent opportunity. Lease
Negotiable. Call Monday — Friday 8-4:00
p.m. 609-883-0500 ext. 30.
EQUIPMENT— For Sale, X-ray, Fisher
300 MS, very little use, reasonable. Call
201-627-2544.
FOR SALE— INTERNIST /CARDIOLO-
GIST/PRACTICE— Recently retired,
moving Autumn 1984 from IV2 acre land-
scaped property with tennis court. Large
home with adjoining 1200 square feet
furnished office, ideal for solo or partner-
ship practice. Office available for rental
occupancy now. Location 8 miles from
Atlantic City and Ocean City, ten
minutes drive to two large modem hospi-
tals, also X-ray and laboratory facilities
nearby. Write or phone: Peter H. Marvel,
MD, FACC, 2216 Shore Road, Northfield,
NJ 08225. Home phone 609-641-2442.
Exchange 609-641-0132.
FOR SALE MEDICAL PRACTICE— Es
tablished. Cardiology & Internal Medi-
cine, Essex County. Office fully equipped,
ready to take over. Grossing $250-8300
thousand yearly with room for signifi-
cant increase. Write Box No. 77, JMSNJ.
FOR SALE OB/GYN PRACTICE— Im
mediately. Northern Monmouth County
near two accredited hospitals in appeal-
ing residential community, will in-
troduce. Call 201-264-7763.
FOR SALE PEDIATRICS PRACTICE—
Long established practice, Z2 block from
hospital. Property and equipment.
Located in Middlesex County. Will in-
troduce. Write Box No. 64, JMSNJ.
PRACTICE SPECIAL OPPORTUNITY—
Large beautiful office, fully furnished and
equipped. Excellent location at bus stop
and near hospital. Can serve 1 or 2 doc-
tors, other health career personnel or
other profession. Available due to phys-
ician’s death. Patients waiting. Contact
Mrs. L. Friedman, 18th and North-
ampton Sts., Easton, PA 18042.
215-252-6341.
FOR SALE OR RENT— For immediate
occupancy, new, modem, energy efficient
building, 500 to 2,000 square feet avail-
able. 31,000 residents within three mile
radius. Close to Philadelphia Atlantic
City. Central Jersey shore area Internists
and specialists needed. Ideal for main/
satellite office. Call 201-350-1008.
FOR SALE OFFICE SPACE— Roselle.
Modem 2.400 square feet. 6 treatment
rooms and 4 consultation rooms, on-site
parking. Warinanco Medical Building.
Phone 201-687-0102.
350
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CLASSIFIED ADVERTISEMENTS
OFFICE SPACE— Available for rent in
fully equipped internist’s office in
Berkeley Heights. For further infor-
mation call 201-376-851 1, 9-5 pm, Mon-
day-Friday.
FOR RENT— Fully equipped and fur-
nished physician’s office just 18 miles
west of Atlantic City, NJ. Call
609-965-1600. Write Mrs. Marie Frank,
227 Philadelphia Avenue, Egg Harbor
City. NJ 08215.
OFFICE FOR RENT— Professional office,
approximately 710 square feet, near
Dover General Hospital. Near Routes 80
and 46. Morris County, NJ Telephone
201-366-2557.
OFFICE FOR RENT— Point Pleasant of-
fice space available on part-time basis in
new professional building. Fully
equipped, including x-ray. Reply Box No.
78, JMSNJ.
OFFICE FOR SHARE— Hudson County
at two locations, near hospitals and
transportation. 201-864-7172.
OFFICE FOR SHARE — Morristown, cen-
tral location. Near hospital, fully
equipped, newly decorated. All utilities
included. Ample parking available. Near
public transportation. Available immedi-
ately. 201-267-2555.
OFFICE FOR RENT OR SHARE— Haz
let-Holmdel area Spacious, furnished
600-1500 square feet, ample parking,
close to hospital. Call 201-264-7763.
FOR RENT/ SHARE— Up to 2000 square
feet in Red Bank opposite Riverview Hos-
pital, ample parking nearby, elevator,
central air, phone 201-747-4127.
OFFICE TO SHARE— Westfield, central
location. Near hospital, fully equipped, at-
tractively decorated. All utilities included.
Ample parking available. Near public
transportation. Available immediately.
201 267-2555.
BOAT FOR SALE — 1982, Sea Ray Sedan,
fly bridge, head, shower, all extras. 26 foot
by 10 ffot. 201-864-7172.
KIAWAH ISLAND— Wild Dunes Beach
and Racquet Club. Charleston, SC re-
sorts. Choice 1-4 bedroom villas for rent.
In prime locations, including oceanfront.
25% owner discount. Brochure 803-556-
6353.
RATE INFORMATION FOR MEMBERS: 85.00 per insertion up to 25 words: 10 cents each additional word. Payable in advance.
WORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
numbers, hyphenated words. Count name and address as five words, telephone number as one word, and ’’Write Box No. 000,
c/o JMSNJ” as six words. COPY DEADLINE: Fifth of preceding month.
PROGESTERONE SUPPOSITORIES
25 mg., 50 mg., 100 mg., 200 mg., & 400 mg.
Boric Acid Suppositories 600 mg.
in both Polyethylene Glycol Base and Fatty Base for
Vaginal or Rectal Use, are now being compounded at
the following Pharmacy
Hidden Lakes Pharmacy
2039 Rt. #27, Somerset, N.J. 08873 201-821-8500
Howard L. Rubenstein, R.Ph.
Specific dosage and ingredient requirements can be tailored
to your patients needs. We specialize in compounding
prescriptions.
Delivery available to your patients home. Cali for
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TAX PREPARATION AND PLANNING
• Individual, Partnership, Corporate, Business, Estate
Services
• Expert Services
• Federal, Any State, Foreign Taxes of any type
• All Year Service
• Audit Representation
• Tax Planning and Reduction
• In Home or In Office Service
H. Michael Zukowski
(201) 945-8443
It’s A Major Medical Explosion
The Lakewood, Toma River and Point Pleasant hospitals
are all going ahead with major expansion programs . . .
Brlcktown to build new facility.
Cross River Professional Center
400 to 2,300 Square Feet
V4 Mile South of Kimball Medical Center
• $9 to $1 1 per square foot minutes to three major
• Graduated rent schedules hospitals
• Ownership options available • Private entrances and all
• Fully landscaped services available
• Centrally located and 10 • Equipment leases available
BMffiYAIOl? ENTcJ?Pl?bEJ> Protected
1200 River Avenue (Route 9), Lakewood, NJ 08701 • (201) 367-2226
TWO MEDICAL SUITES
Available June 1st— Livingston Avenue (Doctors'
Row)— New Brunswick, NJ. Both suites fully carpeted,
sink, closets in each room. One suite has X-Ray room
with equipment.
For Information Please Call
201-828-2715
VOL. 81— NUMBER 4— APRIL 1984
351
CARE FOR YOUR COUNTRY.
As an Army Reserve physician, you can serve your
country and community with just a small investment of
your time. You will broaden your professional experience
by working on interesting medical projects in your com-
munity. Army Reserve service is flexible, so it won’t
interfere with your practice. You’ll work and consult with
top physicians during monthly Reserve meetings. You’ll
also attend funded continuing medical education programs. You will all share the
bond of being civic-minded physicians who are also commissioned officers. One
important benefit of being an officer is the non-contributory retirement annuity you will
get when you retire from the Army Reserve. To find out more, simply call the number
below.
CALL COLLECT OR USE THE COUPON AT BOTTOM:
215-443-1703/1705
CPT HARRY SIMPSON
AMEDD Procurement Office
31-D N. York Road
Hatboro, PA 19040
NAME: , MD/DO
SPECIALTY:
ADDRESS:
TELEPHONE:
BEST TIME TO CALL: _• (AM/PM)
352
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Library
The Journal
of the | Medical
Society of
New Jersey
MAY 1984
Send this coupon
for no-obligation
information
of the savings
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New Jersey
Endorsed
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75 Montgomery St.,
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Best Time To Call.
“AMIDL ANTIC
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FOR THOUGHT
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Bob Van Buren, Chairman ,
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May 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1766
Officers and Trustees
President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
President-elect
Frank Y. Watson, M.D. (Essex) Glen Ridge
First Vice-President
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
Second Vice-President
Edward A. Schauer, M.D. (Monmouth) Farmingdale
Immediate Past- President
Howard D. Slobodien, M.D. (Middlesex) Metuchen
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Douglas M. Costabile, M.D.,
Chairman (1984) (Union) Murray Hill
Frank Campo, M.D. (1984) (Mercer) Trenton
Harry M. Carnes, M.D. (1985) (Camden) Audubon
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
John J. Crosby, Jr„ M.D. (1984) Jersey City
Palma E. Formica, M.D. (1984)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
William Greifinger, M.D. (1984) (Essex) Belleville
John P. Kengeter, M.D. (1984) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Michael R Ramundo, M.D. (1984) (Passaic) Clifton
Publication Committee
Paul J. Hirsch, M.D., Chairman
Direk L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith. M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R. Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1984) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A. Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Albert F. Moriconi, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1984) Haddonfield
Fifth Distfuct
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) AUantie City
AMA Delegates
William J. D’Elia, M.D., Chairman (1985) Spring Lake
Alfred A. Alessi, M.D. (1984) Hackensack
Frederick W. Durham, M.D. (1984) Haddonfield
Palma E. Formica, M.D. (1984) New Brunswick
Karl T. Franzoni, M.D. (1984) Trenton
John S. Madara, M.D. (1984) Salem
Henry J. Mineur, M.D. (1984) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Wm. A. Dwyer, Jr., M.D. (Surg)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Kateher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Heniy R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba, M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa, M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr„ M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of New
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Printing
Co. Whole number of issues 962. Member's subscription ($10) is included in Society dues. Rates for nonmembers,
$20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, Two
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and additional
entry office. Copyright 1984 by the Medical Society of New Jersey.
354
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
mm
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■4 The Upjohn Company
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The Journal
of the Medical
Society of
New Jersey
MAY 19#
Features
359 Membership Newsletter
365 Professional Liability Commentary
37 1 Editorial
Contributions
377 Selection of a Medical Office Computer System
J.W. Allen, M.D., River Edge
383 The Psychological Impact of Cancer on Patient and Family
BA Singer, Ph.D., Cheny Hill
389 Medical History: Alabama Granny Midwife
L. Holmes, M.PA, Newark
393 Case Report: Extra-anatomic Bypasses in Aortoenteric Fistulas
C.H. Antinori, M.D., E.H. Kain, M.D., JA Kuchler, M.D., V.J. Manuele, M.D.,
L. Pierucci, Jr., M.D., D.T. Villanueva, M.D., Camden
399 Case Report: Pancreatic Pseudocyst Associated with Valproic
Acid Therapy
AM. Baskies, M.D., Willingboro
404 Case Report: Familial Dysalbuminemic Hyperthyroxinemia —
A Variant
M. H. Goldman, M.D., and K. Klinges, M.D., Englewood
406 Commentary: DRG— New Jersey and the Federal System
BA Rineberg, M.D., New Brunswick
409 Commentary: DRG— The Executive Director’s View
VA Maressa J.D., Lawrenceville
411 Imaging: An Approach to the Diagnosis of Cholecystitis
L.S. Zeiger, M.D., Camden
415 Current Nutrition: Diet and Nutrition in Chronic Renal Failure
N. Lasker, M.D., Newark
42 1 Opinion: Overcoming Psychic Numbing
B. Grossman, M.D., Trenton
Doctors’ Notebook
423 Trustees’ Minutes: March 18, 1984
424 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
424 AMNJ Report, Paul J. Hirsch, M.D.
425 Diagnostic Virology Report
426 Physicians Seeking Location in New Jersey
MSNJ Departments
429 CME Calendar
433 Book Reviews
435 Obituaries
436 Information for Authors
On The Cover: John Bowe,
M.D., is a member of our
Bergen County component
and an artist. The cover, en-
titled “Batsto River, New
Jersey,” is just one of Dr.
Bowe’s many paintings.
356
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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return the coupon below today. He is ready to answer the many
diverse financial questions that probably only another health
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Dr. Sarantos:
Please contact me regarding the following area of interest:
□ Developing a financial plan
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Name-
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□ Insurance review
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or 201-539-4000 (N J only)
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FINANCIAL SERVICES, INC.
240 Cedar Knolls Rd, Cedar Knolls, NJ 07927 J
•L. 81— NUMBER 5— MAY 1984
357
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358
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
THE MEDICAL SOCIETY OF NEW JERSEY VOLUME 11
MEDICARE LEGISLATION ADVANCES
SIGNIFICANT CHANGE
The Senate Finance Committee recently adopted a
$50 billion spending-eut package that contains three
specific Medicare proposals of major interest to the
profession. These are:
1. Imposition of a three-month freeze on physician
Medicare payments.
2. Introduction of a participating physician concept
to be triggered in after the three-month freeze. It would
permit those accepting assignment 100 percent of the
time to obtain Medicare payment increases. No in-
creases would be given to those physicians accepting
assignment less than 100 percent of the time. Other
administrative incentives also would be applied for
those agreeing to be participating physicians.
3. Development of fee schedules for both in- and
out-of- hospital clinical laboratories to restrict Medi-
care payments to 62 percent of the prevailing-fee rate
for laboratory services for 3'/2 years.
The three provisions were adopted by an over-
whelming majority in a package vote.
The Senate Finance Committee cited as its justifi-
cation for creating the participating physician concept
the need to stem efforts of some congressional leaders
to push for mandatory assignment. The Senate
Finance Committee took up a $50 billion revenue
package on Tuesday, February 28. The Committee also
will be looking at modifications of the DRG rates rela-
tive to intensity. The House Ways and Means Commit-
tee currently is determining how the full House should
deal with the proposed Medicare issues including
mandatory assignment.
RULES COMMITTEE ACTION ON MEDICARE
At the start of this month, it appeared that H.R.
4170, the Tax Reform Act, would be considered on the
floor of the House at any moment. This bill contained
38 proposals to modify the Medicare program, and also
was scheduled to be a vehicle for a committee amend-
ment to be offered on the floor of the House by Chair-
man Dan Rostenkowski (D-IL). The so-called
“Rostenkowski amendment” would have proposed a
one-year freeze on physician reimbursement, coupled
with a requirement of acceptance of Medicare assign-
VOL. 81— NUMBER 5— MAY 1984
ment for all hospital inpatient services provided to
Medicare beneficiaries.
H. R. 4170 was considered before the Rules Commit-
tee on March 7. The Texas congressional delegation
had requested the opportunity to offer an amendment
to H.R 4170 that would allow for a straight one-year
freeze on the Medicare prevailing charge without any
linkage to mandated assignment. However, before the
Rules Committee could act on this request. Con-
gressman Rostenkowski unexpectedly requested that
the Medicare cuts and other spending cuts contained
in H.R 4170 be separated from the bill, with only the
tax provisions going to the House floor. Subsequently,
H.R 4170, minus the Medicare and other spending cut
measures, was cleared for House floor action; the
Rostenkowski amendment would not be in order as an
amendment to the bill.
The precise future course of the Rostenkowski
amendment is uncertain at the moment, but it un-
doubtedly will arise again attached to another bill or
incorporated in a reconciliation measure.
AMA STATEMENT ON VOLUNTARY FEE
RESTRAINT
On February 23, the American Medical Association’s
Board of Trustees unanimously authorized sending a
letter to each physician in the United States, urging
him or her:
I. To freeze fees for a one-year period, beginning
immediately: and
2. To continue to take into account the financial
circumstances of each of his or her patients—
especially the unemployed, the uninsured, and those
under Medicare — and to accept reduced fees when
warranted.
Traditionally the AMA with support from physicians
across the country, has been in the forefront of assur-
ing that the profession will do its fair share in provid-
ing cost-effective medical care. For example:
• The inaugural address of the AMA president six
years ago also asked physicians to decrease the rate
of increase in their overall charges.
• In 1978, the AMA endorsed a voluntary program
to restrain the rate of increase in physicians' fees, a
program that resulted in the physician services corn-
359
ponent of the consumer price index (CPI) registering
below the all-items index.
• The Association continually has asked physicians
to reduce or waive fees for the unemployed and others
who have lost public or private insurance benefits. In
response many local medical societies have set up pro-
grams to serve the temporarily unemployed.
• Several state medical associations recently have
asked their members voluntarily to freeze their fees.
PREFERRED PROVIDER ORGANIZATIONS (PPOs)*
The decision to join or organize a PPO is not an easy
one for physicians. If the decision is whether or not
to participate in a PPO or other selective contracting
arrangement, then the physician needs to evaluate
carefully the contracting entity, the contract itself, and
the implications that this new way of doing business
may have for his medical practice and his relationship
with patients. The physician who is deciding whether
or not to organize a PPO must, in addition to the above
concerns, consider the need for and feasibility of a PPO
in his or her community. Before any organizational
steps are taken, it is imperative that the physician or
group of physicians who are laying the potential
groundwork become very well informed about PPOs
and their advantages and disadvantages. The more
detailed operational knowledge of PPOs physicians
possess, the better they can present an accurate pic-
ture to their colleagues.
Physicians are interested in organizing or signing a
contract with a PPO for many reasons. The concept has
both advantages and disadvantages, however, and
there are some reasons for physicians to avoid affiliat-
ing with a PPO.
As earlier discussed, some advantages enjoyed by
physicians in these types of arrangements include a
potentially larger patient base, the lack of significant
financial risk (in most cases), and the opportunity to
participate and still maintain a fee-for-service office-
based practice. However, physicians should recognize
that there may be no assurance of an increased
number of patients unless the PPO provides for a pa-
tient lock-in.
Disadvantages which can occur with participation
in a PPO include discounted fees (if, for example, the
PPO does not deliver the expected increase in volume
to offset the discount, the physician will lose money
overall), and the negative effects of certain contract
provisions offered by some PPOs. Again, as earlier dis-
cussed, the physician must make certain he has a clear
understanding of all terms and obligations in the con-
tract before signing it. It is advisable to use legal coun-
sel for this purpose. Contract clauses which serve to
increase a physician's liability for malpractice or to
limit unreasonably the scope of a physician’s practice
or professional judgment should be avoided.
The organization of a PPO is usually a response to
the increased competitiveness of the medical care mar-
ketplace. Many proponents see these organizations as
an effective means of combating the competitive pres-
sures of other alternative delivery systems or an in-
* Reprinted with permission from A Physician's Guide to
Preferred Provider Organizations, American Medical Associa-
tion, 1983.
creased supply of physicians in an area
A disadvantage for a physician involved in a PPO can
be the loss of control over some of the decision making
in medical care delivery (and, therefore, over the pa-
tient’s welfare) to hospital administrators, third
parties, or insurers through the administration of the
contracting process. Many physicians believe, however,
that this problem is not inherent in selective contract-
ing, but rather that it is a function of who controls the
contracting process (usually the PPO sponsor or de-
veloper). Consequently, many physicians are eager to
maintain a leadership role in the design of the PPOi
and its fee schedule, procedures, and contracts, rather
than surrender that control to insurers, hospital ad-
ministrators, and third parties. The current legal
climate regarding the establishment by physicians of
physician fee schedules or agreements, however, is in-j
hospitable. As earlier discussed, physician sponsor-
ship or organization of a PPO best may be ac-
complished through the establishment of a true joint
venture in order to avoid allegations of price-fixing
However, characteristic of a joint venture is the ability!
to offer some new previously unavailable service as a,
result of the joint venture, or the joint risk of capital
investment.
For both physicians contemplating participation in
an PPO and physicians interested in organizing a PPO.!
the initial step must be to learn as much about thel
topic as possible. Several helpful, substantial articles
have appeared in magazines and journals within re-
cent months. Some are case studies of individual
plans. There also are detailed manuals on the subject
of selective contracting which are available. Thesei
manuals provide a great deal of technical information,
on the issues involved in selective contracting and give
detailed advice on the steps involved in putting such
an organization together; however, they have been
compiled by groups in California and are therefore!
particularly relevant to the legal and regulatory climate;
in California at the moment. They also have a tendency
to be very hospital-oriented.
Physicians also will find it helpful at this stage tc;
talk to people who have been involved in this process!
Conferences and workshops on the topic are given
periodically by various groups and provide a good
forum to acquire a working knowledge of the topic :
exchange ideas, and meet people who have been in
volved in these organizations.
Another productive way to learn how a PPO func1
tions is to visit some operating plans. Most physicians
and administrators are generous about sharing their!
expertise; however, it helps to focus the discussion i: t
the visitor has done some background research anc ;
comes prepared with a list of questions.
During this information-gathering period, the
number of people learning about PPOs should in si
crease. The first discussions probably will involve onl}
a few physicians. It is important that knowledge based ft
on accurate information be shared by an ever-widen
ing circle of peers. Before any concrete steps are taker1
to begin a feasibility study, to hire consultants, or tc ft
seek funding, the physician organizers should be sun
to have informal talks with physician leaders in vari |
ous segments of the medical community.
These early conversations should be small and infor
360
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
nal to facilitate an exchange of ideas and information,
^ater, when a basic foundation of information and
^operation has been laid, a larger meeting is ad-
visable, with experienced PPO administrators and
Dhysicians invited to address the group. If adequate
Dreparation has been made, through small, infor-
national meetings, attendance at the community-wide
neeting should be larger, better informed, and more
-eceptive.
If the community, having learned about the concept
i>f a PPO, is either uninterested or hostile, the organiz-
ing group should recognize the difficulties of going on
Aith the project. If, on the other hand, there is a suffi-
:ient number of physicians in the community
interested in pursuing selective contracting as a part
}f their practice, then the organizers should consider
undertaking a formal analysis of the feasibility and
marketplace acceptance of the establishment of a PPO
in their community.
A PPO's early educational efforts are appropriately
focused on physicians and hospitals. However, at some
later point in the process of gathering information, it
is important to apply similar communication and
educational efforts to the nonphysician community.
The PPO developers will need to communicate with
representatives from industiy and unions, insurance
Harriers, and other health organizaitons. The timing of
this stage of activity will differ from one situation to
another. Ideally, it will take place when physician
leaders have acquired sufficient knowledge of PPOs to
have a fairly clear agenda for how they will proceed into
a feasibility study. However, it should not be delayed
too long, because many nonphysician leaders are both
interested in and knowledgeable about the subject of
health care financing and delivery systems. They can
contribute significantly during the early decision and
planning stages. Later, business expertise and ability
to assist with marketing will make industry and labor
representatives valuable members of an operational
plan’s governing board.
Business community acceptance and cooperation is
important to the success of a PPO. The response and
level of interest in the business community should be
assessed and a decision made regarding the existence
of enough potential support to ensure access to large
numbers of the area’s employees. If support is lacking
or there is very little interest, again the physician or-
ganizers should recognize the difficulties inherent in
continuing with the project.
If sufficient support and interest exist for the con-
cept of a PPO to appear viable, then the next step for
the PPO developers is a careful market analysis, includ-
ing the development of a marketing plan, and to begin
to develop the organizational policies and procedures
which will govern the activities of the PPO. The phy-
sician developers should be aware that even while the
development of policies and procedures is occurring,
the market analysis may turn up reasons why the PPO
may be unsuccessful. When and if such issues do sur-
face during the planning process, the developers
should be prepared to consider seriously whether they
represent an insurmountable obstacle that will in all
likelihood jeopardize the success and survival of the
PPO, or whether they can be dealt with or accommo-
dated as the organization develops.
During this stage of the planning process, many
questions of a highly complex and technical nature will
need to be answered. Specialists or consultants may
need to be brought into the project on a short-term
basis for such tasks as determining the amount of the
premium, setting up an adequate management infor-
mation and data system, and researching all the legal
requirements. There is no substitute for an expert’s
advice on some of these issues, particularly in the legal
and actuarial fields.
Developing a PPO is a difficult and challenging task,
but not an impossible one. There is a growing cadre
of PPO administrators and physicians who have made
the difficult decisions, corrected their mistakes or mis-
calculations, and hammered out what they believe to
be viable programs. Their experiences will be in-
valuable to the potential developers of a new PPO.
Eveiy opportunity should be taken to learn from them
through reading, conferences, and visits to their plans.
During the course of the PPO’s development,
although it may appear incongruous, it is not unusual
to be working toward two different objectives simul-
taneously: deciding whether a PPO should be formed
and planning its formation. In the momentum that
gathers around the planning of a new organization, it
is imperative that the basic questions not go unasked.
Honest answers will indicate the likelihood of the
plan’s ability to succeed. Is there a well defined need
for a PPO solution to the problem, as opposed to
another alternative solution such as an HMO? Is there
enough commitment on the part of physicians in the
community? Are there enough employers who are suf-
ficiently committed to the concept not only to make the
PPO option available but to provide enough infor-
mation so that employees can make an informed
choice? Are there enough people who, when offered the
option of the PPO, will find it accessible and economi-
cally attractive enough to choose?
In the construction of the new organization, careful
policy decisions must be made about its structure and
composition. Will there be one corporate entity, or two?
Will it be a joint venture arrangement? Who will serve
on the governing board? What will be the criteria for
physician participation? For hospital participation?
What payment mechanisms will be worked out? Will
the physicians share any economic risk? What
procedures will be used for reviewing utilization and
quality? There may not be easy consensus on these
difficult questions. However, taking the path of least
resistance during the planning stages can prove
troublesome later, when the operating plan is tiying
to keep all parts of its budget under control and tiying
to avoid allegations of anticompetitive behavior.
It is usually helpful to seek the counsel of physicians
in other communities who have gone through the
same experiences. Their detachment from local issues
can lend objectivity when opinions or even per-
sonalities begin to conflict. And, of course, competent
experienced staff and consultants can aid tremen-
dously in defining the options that are available and
recommending what they believe is the best course of
action.
In the final analysis, though, the ultimate decision-
making responsiblity lies with those who are develop-
ing and designing the plan for their own community.
VOL. 81— NUMBER 5— MAY 1984
361
Remaining actively involved in the planning process
over a span of many months can be a demanding and
tiring experience. It can also be a rewarding one, if the
ultimate result is an organization about which phy-
sicians can feel satisfied and confident.
SENATE FINANCE COMMITTEE ACTIONS
The Senate Finance Committee has held a number
of meetings since February 23 to consider a series of
deficit reduction options. None of the options under
consideration has been introduced in bill form, and
they are subject to modifications. In the course of these
meetings, the following recommendations on spending
reductions that relate to the Medicare and Medicaid
programs have been developed:
Participating Physicians— Physicians’ prevailing
fees would be frozen for at least three months begin-
ning in April 1984 and the freeze would continue for
an additional two years for those physicians unwilling
to agree to accept assignment for all services provided
to all of their Medicare patients for the following fee
screen years. Incentives also would be developed to
encourage physicians to accept assignment on all
claims. These include publicity of their status as “par-
ticipating physicians,” electronic claims processing for
beneficiaries with Medigap coverage, and simplified
billing/payment arrangements. Physicians who do not
elect to accept assignment for all of their Medicare
patients will continue to have the option of assigning
claims on a claim-by-claim basis.
Fee Schedule for Clinical Laboratory Services — A
fee schedule would be established for clinical labora-
tory services where payments would be reduced to 62
percent of the prevailing charge levels for all laboratoiy
services payable under Part B. The fee schedule would
be in place for 3'/2 years, until October 1987.
Increase in Part B Premium — The Part B premium
would be increased from 1985 to 1990 so that the
premium would equal 35 percent of the cost of the Part
B program by 1990.
Date of Initial Eligibility for Medicare Entitle-
ment— Eligibility for both Parts A and B of Medicare
would be delayed to the first day of the month following
the month of an individual’s 65th birthday. (Eligibility
now occurs on the first day of the month in which an
individual attains age 65.)
Working Aged — Where a nonworking spouse is aged
65 to 69 and the working spouse is not yet 65 years
of age, the nonworking spouse would have the option
of electing primary coverage under the employer group
health plan. (Under current law, both the employed
individual and spouse must be between the ages of 65
and 69 to create a situation where Medicare could be
secondary payor.)
Limiting Increases in Hospital Reimbursement—
The rate of increase in hospital reimbursement would
be limited for fiscal years 1985 and 1986 to just the
hospital market basket. (Under current law, rates will
be allowed to increase at the rate of market basket plus
1 percent.)
Reduction in Medicaid Payments— Federal reduc-
tions in matching payments for states would continue
for an additional three years. The reduction would be
at 3 percent for fiscal years 1985, 1986, and 1987.
Existing offsets whereby states may qualify to earn
back part of all of the reductions would remain ii \
place.
Medicaid Assigment of Rights— States would be re
quired to have all Medicaid applicants assign to th
state their rights to any third-party recovery for healtl
care costs. (Current law gives states the option to re
quire Medicaid applicants to assign these rights to th
state.)
GLUTETHIMIDE RESCHEDULED
Glutethimide, the nonbarbiturate sedative has beer
rescheduled in the New Jersey Controlled Dangerou;
Substances regulations from Schedule III to Schedul
II effective February 21, 1984. A final notice of adoptioi
appeared in the New Jersey Register. This drug prod
uct is prescribed under the generic name o
glutethimide as well as the brand name Doriden®, USV
As a Schedule II drug, the following restriction:
apply:
1. Only a written prescription may be used t(
prescribe glutethimide.
2. The prescription is nonrefillable.
3. A prescription for glutethimide may not be writ
ten for a quantity greater than a 30 day supply or ;j
120 dosage unit whichever is the lesser amount.
4. Records of purchase of glutethimide must be kep
separate from all other records.
5. Prescriptions for glutethimide must be kept on £
separate file.
Since this is a change under New Jersey’s code only
the need for a federal triplicate order form (DEA-222
is not required.
For additional information on this change, cal;
609-984-1308.
NJ AUTO INSURANCE FREEDOM OF CHOICE AND
COST CONTAINMENT ACT OF 1984
Assembly Bill #3981, known as the New Jersey Auto
mobile Insurance Freedom of Choice and Cost Con
tainment Act of 1984, was passed by the State Senat(
on October 3, 1983, and signed by the Governor th
next day.
Section 13 of the legislation requires every auto
mobile insurer to offer, on an optional basis, medica
expense benefit deductibles in amounts of $500
$1,000, and $2,500 for any one accident for any one
person with respect to personal injury protection cov
erage, provided in accordance with the law. If an indi
vidual elects one of these deductibles a reduction of 1(
percent to 40 percent of the cost for personal injur}
protection, or about $30 a year on the average, will be
realized. The deductible selected will be applied before
medical expenses are compensable under the insured's
automobile policy.
If the insured injured person has other hospi
tal/ medical coverage, such as offered by our Programs
medical expenses used to satisfy the automobile in
surance deductible may be submitted to that medical
care insurance plan for consideration. The law does
not require medical care insurance plans to reimburse
fully for the amount of expenses used to satisfy the
automobile insurance deductible: those expenses
would be subject to the other medical care insurance
362
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Man's policy provisions as to deductibles, copayment,
neligible expenses, and maximum benefit.
The Committee on Medical Defense and Insurance
vishes to caution the Society’s membership that the
election of one of these deductibles and the resulting
rniall savings in the cost of automobile insurance may
lot be worth the added risk of having to pay any or
ill of the expenses used to satisfy the deductible for
lersons insured under his or her policy.
AMENDMENT TO SPECIALIST RULE
The Division of Medical Assistance and Health Ser-
vices of the state of New Jersey's Department of Human
Services has proposed a rule which will delete the re-
quirement that in order to be paid as a specialist (by
dedicaid) a physician must limit his/her practice to
10 percent of their specialty.
The proposed new rule will allow physicians who
qualify as specialists to be reimbursed accordingly,
lowever, physicians must be classified as specialists
qy the Prudential Insurance Company, the fiscal agent
vho is responsible for processing physician claims for
layment.
Note: No action is required if the physician already
Is classified as a specialist by the Medicaid program.
The full text of the proposed rule will appear in a
ubsequent issue of the New Jersey Register.
INAL PROSPECTIVE PAYMENT
SYSTEM REGULATIONS
While Health Care Financing Administration regu-
Iitions on the prospective pricing under Medicare are
i constant fluctuation, several significant actions
ave been taken. These are listed below. Please bear in
lind that they refer to federal Medicare and not to the
lew Jersey DRG Program.
Outlier Funding. HCFA has eliminated the hospital
pecific portion from outlier funding. Consequently,
ayments for outliers will become smaller while pay-
lents for nonoutlier cases will be increased.
Excluded Hospitals. Alcohol/drug treatment hospi-
als and units are excluded from federal DRGs until
'ctober 1985.
Charges to Beneficiaries. Hospitals may bill for ser-
ices to patients who elect to remain in the hospital
>r more than two days past the date the patient is
otified that acute care no longer is necessary.
Physician Attestation. A physician must, proximate
) discharge, attest in writing to the principal
iagnosis, the secondary diagnosis, and the names of
re procedures performed. Intentional misrepresenta-
on, concealment, or falsification may be punishable
y imprisonment, fine, or civil penalty.
PORTS MEDICINE AND THE HANDICAPPED
On May 25, 1984, a special symposium entitled,
sports Medicine and the Handicapped,” will be held
t the Meadowlands Sports Complex. This day-long
/ent is sponsored by the New Jersey Orthopaedic So-
ety in affiliation with the New Jersey Special Olym-
ics, UMDNJ-New Jersey Medical School, United Chil-
ren’s Hospital, and United Children’s Hospital Or-
thopedic Center. The coordinator and moderator is
Max M. Novieh,' M.D. For further information, please
contact the New Jersey Orthopaedic Society.
STEPHEN WICKES PRIZE
The Medical History Society of New Jersey is pleased
to announce the establishment of the Stephen Wickes
Prize in the Histoiy of Medicine. This annual award
of $100 is named for Stephen Wickes, the first medical
historian in New Jersey. Any currently enrolled under-
graduate, graduate, or professional student is eligible
to submit an original essay on a historical subject in
medical or allied fields. The topic may treat the histori-
cal aspects of a current problem, or it may deal with
a specific subject in a defined period of the past.
The Committee particularly is interested in topics
related to the history of medicine or allied fields in New
Jersey. Essays should not exceed 7,000 words and
should be submitted by August 1, 1984, to: Chairman,
The Stephen Wickes Prize in the History of Medicine,
Medical History Society of New Jersey, Two Princess
Road, Lawrenceville, NJ 08648.
No awards will be made if entries submitted are
deemed to be without sufficient merit. The essay
selected as the winner by the Committee will be sub-
mitted for consideration toward publication in The
Journal of the Medical Society of New Jersey.
MEDICAL HISTORY SOCIETY OF NEW JERSEY
MEETING
The Medical History Society of New Jersey, in affilia-
tion with the Academy of Medicine of New Jersey, will
meet at the Medical Society of New Jersey’s head-
quarters in Lawrenceville on Wednesday, May 9. Lester
S. King, M.D., well-known historian of medicine, will
deliver the annual Morris H. Saffron Lecture, “When
Did Medicine Become Scientific?” A pathologist by
training, Dr. King long has been interested in the his-
tory of the profession.
HEALTH CARE COSTS
A pamphlet prepared by the Office of Public Affairs
and Medical Education, MSNJ, now is available for
distribution. The brochure is a patient education tool
that discusses the high cost of health care and what
physicians in New Jersey are doing to control the prob-
lem.
A recent national survey showed that one of the
greatest concerns of all physicians is high health care
costs. The national health care dollar is spent in the
following manner: 41 percent for hospital care, 21 per-
cent for personal health care, 19 percent for phy-
sicians’ services, 1 1 percent for other health spending,
and 8 percent for nursing home care.
You can order this informative pamphlet for office
distribution by calling the Public Affairs Office, MSNJ,
at 609-896-1766.
FINI
The highest thing in leadership is credibility.
)L. 81— NUMBER 5— MAY 1984
363
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>ROFESSIONAL LIABILITY
Commentary*
The New Jersey Supreme Court
has permitted attorneys to in-
crease their contingency fees be-
nning January 16, 1984. A contingency fee, which is
ased on the amount of an award in a civil action, is
t agreement between the client and the attorney on
te fee the attorney will receive for his services. The
-w contingency fee limits are: 33'/3 percent of the first
150,000; 25 percent of the next $250,000; and 20
1‘rcent of the next $500,000. (On a $500,000 award,
te fee would be $145,825.) The previous contingency
e limits were: 50 percent of the first $1,000; 40 per-
mit of the next $2,000; 331/3 percent of the next
17,000; 25 percent of the next $50,000; 20 percent
the next $150,000; and 10 percent of any amount
er $250,000. (On a $500,000 award, the fee was
39,451.)
Under Court rules, all contingency agreements in
pw Jersey must be in writing prior to the start of the
Use. If the client is an infant or incompetent at the
ne the contingency fee is made, the fee in settlement,
iithout trial, cannot exceed 25 percent.
,The Supreme Court also established a new rule for
lyment in the event the plaintiff receives funds on
i installment basis, otherwise known as a structured
ttlement. The new ruling calls for contingency fees
i be based upon any cash payment made at settle-
ent plus the actual cost to the party making the
Jtlement of the structured settlement. Prior to this
-W ruling, the contingency fee was based on the total
the structured settlement. New Jersey is one of six
ates in the nation that limit contingency fees.
WHY ENGLAND HAS FEWER MALPRACTICE SUITS
The annual premium charged in 1982 by the Medi-
cal Defense Union, the largest and oldest of Britain’s
three malpractice insurers, was approximately $250.
In the 25 years from 1947 to 1972, only 2,809 malprac-
tice claims were brought, compared to the United
States which closed IV2 times as many claims for 1976
alone.
This information, along with reasons why England
has fewer malpractice claims, was part of an article on
the British health care system which appeared in the
January 5, 1984, issue of the New England Journal
oj Medicine.
The authors of the article, William Schwartz, M.D..
and Henry Aaron, M.D., contend that among the many
impediments to plaintiffs bringing malpractice suits,
is the initial cost to the plaintiff. The plaintiff must pay
his lawyer a predetermined fee to initiate a suit rather
than arrange a contingency fee. Should he lose, the
plaintiff also must pay the defendant's costs— typically
as of 1971 in the range of $7,500 to $25,000. The Legal
Aid scheme entitles indigent plaintiffs to sue at gov-
ernment expense, but few qualify because "indigency"
requires disposable income to be less than roughly
$3,500 per year.
ATTORNEYS PERMITTED TO ADVERTISE
For the first time, lawyers will be allowed to solicit
customers via the electronic media, but do not expect
to hear any catchy jingles. The New Jersey Supreme
Court recently ruled that lawyers may advertise on
radio and television as long as the ads are tasteful and
do not misrepresent any facts.
The ruling prohibits the use of “drawings, anima-
tions, dramatizations, music, or lyrics" as well as any
comments on win-loss records or influence with the
courts.
Another major change in the rule that will permit
lawyers to advertise on radio and television is a section
that will permit out-of-state firms the right to solicit
business as long as “the name of an attorney licensed
to practice here clearly is set forth in all communica-
tions" and that the attorney be responsible for the New
Jersey office's operations.
Previously, the out-of-state firm of Jacoby and
Meyers was ruled ineligible to advertise or solicit busi-
ness here because neither of those attorneys was
licensed to practice law in the state. (The Trentonian,
Friday. January 20, 1984)
MEDICOLEGAL SEMINAR
The Medical Society of New Jersey's Department of
Professional Liability Control, in conjunction with the
Medical Inter-Insurance Exchange of New Jersey, is
planning its fifth annual medicolegal seminar for
Wednesday, September 12, 1984. Details of this sem-
inar will be mailed to members in early August.
‘This item from the Department of Professional Liability Con-
trol. MSNJ. was prepared by James E. George, M.D.. J.D.. and
A. Ronald Rouse who are. respectively. Director of the Depart-
ment and Director of Special Projects.
)L. 81— NUMBER 5— MAY 1984
365
CALIFORNIA HOSPITALS REQUIRE MD
COVERAGE
More California hospitals are requiring physicians
to carry professional liability insurance as a condition
of maintaining staff privileges. A recent survey con-
ducted by the California Hospital Association found
that half of the hospitals in the state require such
coverage and another 22 percent are considering im-
posing such a requirement.
This information reflects about a 17 percent in-
crease in hospitals with such a stipulation. A survey
conducted by the California Medical Association’s
Task Force on Professional Liability of all 505 hospitals
in the state in late 1981 and early 1982 showed that
of the 77 percent who responded, only 32.8 percent
required proof of coverage to retain medical staff privi-
leges. Fifty-nine other hospitals said they were con-
sidering doing so. At that time, of 221 hospitals who
said they do not require coverage, 47 said they never
had considered it and 115 had considered but rejected
the idea
A California appeals court ruling handed down June
28, 1983, may have given impetus to the increase in
hospitals requiring insurance coverage. In Wilkinson
v Madera Community Hospital (Civ. 6109), the court
not only recognized the right of a hospital to require
its physicians to carry malpractice insurance, but to
specify further the type of insurance and the nature
of the carrier with whom the insurance was placed.
The court even went further, indicating that the in-
surance requirement was a move in the best interests
of hospitals, physicians, and patients.
In Wilkinson, a physician went to court to contest
a hospital board of trustees' resolution requiring all
medical staff members to maintain malpractice in-
surance with a “recognized insurance company in a
minimum amount of $500,000 per occurrence.” The
case went up on appeal. The plaintiff, whose insurance
was placed with an offshore carrier, argued that the
insurance requirement and the specifications were
unconstitutional on a variety of grounds, among them
denial of due process and violation of the equal protec-
tion clause. The court rejected each argument, uphold-
ing the validity of the insurance requirement, and say-
ing: “In light of the increasing number and amount of
personal injury verdicts against doctors and hospitals,
it is highly germane to consider a hospital’s interest
in having its staff doctors insured in an adequate
amount and by a reliable carrier. Such coverage
protects the vital financial integrity of a hospital. It
provides an assured fund to pay a judgment where the
doctor is held personally liable. If by reason of the
relationship between doctor and a hospital, the hospi-
tal is held jointly liable with the primarily responsible
doctor, the hospital would have the right of indem-
nification against the doctor and the doctor’s carrier.
Thus, the existence of malpractice insurance covering
staff doctors would likely reduce the insurance
premium on the hospital’s liability coverage. Lastly, the
existence of such coverage protects hospital patients.”
In a memo to California hospitals, Musick, Peeler,
and Garrett, California Hospital Association’s legal
counsel, pointed out that the decision was not fina
and that there was a possibility that there could be £
petition for rehearing or for a hearing before the Cali
fomia Supreme Court.
Even so, the impact of the appeals court ruling is
reflected in the recent California Hospital Associatior
survey which revealed that about 72 percent of al
California hospitals either already require proof of cov
erage from medical staff members or are considering
such a requirement. More than half of the hospitals
now requiring coverage say that the carrier must b<
recognized by the state department of insurance, bu
only 15 percent specify whether the insurance mus
be a particular type — claims made or occurrence
About 80 percent require a minimum amount of cov
erage with the greatest majority (43 percent) requiring
limits of $500,000/$! million. Another 33 percen
specify coverage of $l/$3 million and 21 percent re
quire $500,000 or less.
“Nearly 60 percent of the nonprofit hospitals re
plying to the survey require coverage, while just unde
40 percent of the investor-owned hospitals do,” saic
the California Hospital Association. (Medical Liability
Monitor, Vol. 8, No. 12, December 24, 1983)
AETNA LIFE & CASULTY “NO LONGER A MAJOR
FACTOR” IN MALPRACTICE MARKETPLACE
Aetna, once the dominant carrier in eight states anc
doing business in many others, is pulling out of th<
malpractice market. Aetna spokesman, Matthew M
Sheridan, says the company is trying to withdraw fronj
the “unprofitable” line very gradually by notifying th<
insured that his or her policy will not be renewed.
“We are no longer a major factor in medical malprac
tice and the areas we still are active in represent onhl
a small percentage of the total market” said Mrjj
Sheridan. Aetna says it still is active in about ter
states, but the giant insurer will not specify whicl
markets those are. Sheridan also declined to say hov,
many physicians and surgeons still are covered b
Aetna
The reasons for Aetna’s withdrawal are varied, bu
there is reason to believe the insurer, one of the na(
tion’s largest, could not compete with the rise in sel»
insurance and medical and hospital associations pool?
ing resources to underwrite their own professiona
plans. Aetna says it could not keep pace with the larg
medical malpractice settlements even with increasin
its rates. The company would not confirm or den
recent reports that it is abandoning the states of Mis
souri, Maine, Kentucky, and Wisconsin, but the retrea
is in the works, according to sources.
The Iowa Medical Society, for one, hopes that Aetn
is not getting out of its state. The Society has had
sponsored program with the insurer since 1977. Abou
1,250 physicians are enrolled in the plan. The ir
surance company has asked the Iowa insurance com
missioner to approve a 32.5 percent rate increase fo
February 1, 1984, but so far, no action has taken plac
on that request. (Medical Liability Monitor, Vol. 9, Nc
1, January 30, 1984)
366
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E. ’
The P.A.C.E program takes into account
the kind of medicine you practice, and where |
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program, A
for more information please call A
(201) 456-3200.
The card that you can count on...
Blue Shield
of New Jersey
v m
WITH
COMPLETE
SLEEP LABORATORY
PROOF15...
U* ■ '•
Copyright^ 1984 by Roche Products Inc. All righrs reserved
ONLY DALMANE
flurazepam HCI/Poche
IMPROVES SLEEP...
M ALL THESE WAYS
lapid sleep onset1'6
effective for middle-of-the-night
and early-morning awakenings2,5
Jndiminished efficacy for at
least 28 nights2'4
atients usually awake rested
and refreshed79
voids rebound insomnia after
discontinuation of therapy35,1012
ution patients about driving, operating hazardous machinery or dnnk-
; alcohol during therapy. Limit dose to 15 mg in elderly or debilitated
tients. Contraindicated during pregnancy.
iiND THE
IREDICTABILITY
(HAT COMES WITH
IXPERIENCE
FOR EFFECTIVE REUEF OF INSOMNIA
DALMANE
flurazepam HCI/Roche
STANDS APART .
15-MG/30-MG
CAPSULES
See next page for
references and summary
of product information.
References: 1. Kales J et al: Clm Pharmacol
Ther 12: 691-697, Jul-Aug 1971. 2. Kales A et al:
Clin Pharmacol Ther 18: 356-363, Sep 1975.
3. Kales A et al: Clm Pharmacol Ther 19:
576-583, May 1976. 4. Kales A et al: Clin Phar-
macol Ther 32: 781-788, Dec 1982 5. Frost JD Jr,
DeLucchi MR: J Am Genatr Soc 27:541-546, Dec
1979 6. Kales A, Kales JD: J Clm Pharmacol
3 140-150, Apr 1983. 7. Monti JM: Methods Find
Exp Clm Pharmacol 3: 303-326, May 1981.
8. Greenblatt DJ et al: Sleep 5 (Suppl 1):S18-S27,
1982 9. Kales A et al Pharmacology 26 121-137,
1983 10. Greenblatt DJ, Allen MD, Shader Rl:
Clm Pharmacol Ther 21 355-361, Mar 1977.
11. Zimmerman AM: Curr Ther Res 13 18-22,
Jan 1971 12. Amrein R et al: Drugs Exp Clm Res
9(11:85-99, 1983.
If your professional
liability insurance company
ran out of money, you could
find yourself very much . . .
Dalmane,J ®
flurazepam HCl/Roche
Before prescribing, please consult complete product infor-
mation, a summary of which follows:
Indications: Effective in all types ol insomnia characterized by
difficulty in falling asleep, frequent nocturnal awakenings and/
or early morning awakening; in patients with recurring insom-
nia or poor sleeping habits; in acute or chronic medical situa-
tions requiring restful sleep. Objective sleep laboratory data
have shown effectiveness for at least 28 consecutive nights ol
administration. Since insomnia is oflen transient and intermit-
tent, prolonged administration is generally not necessary or rec-
ommended. Repeated therapy should only be undertaken with
appropnale patient evaluation
Contraindications: Known hypersensitivity to flurazepam HCI;
pregnancy. Benzodiazepines may cause fetal damage when
administered during pregnancy. Several studies suggest an
increased risk of congenital malformations associated with ben
zodiazepine use during the first trimester. Warn patients of the
potential risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam Instruct patient to
discontinue drug pnor to becoming pregnant. Consider the pos-
sibility of pregnancy prior to instituting therapy.
Warnings: Caution patients about possible combined effects
with alcohol and other CNS depressants. An 'additive effect
may occur if alcohol is consumed the day following use lor
nighttime sedation. This potential may exist for several days
following discontinuation. Caution against hazardous occupa-
tions requiring complete mental alertness (e g. . operating
machinery, driving). Potential impairment ol performance of
such activities may occur the day following ingestion. Not rec-
ommended for use in persons under 15 years of age. Though
physical and psychological dependence have not been reported
on recommended doses, abrupt discontinuation should be
avoidecl with gradual tapering of dosage lor those patients on
medication lor a prolonged period of time. Use caution in
administering to addiction-prone individuals or those who might
increase dosage.
Precautions: In elderly and debilitated patients, it is recom-
mended that the dosage be limited to 15 mg to reduce nsk of
oversedation, dizziness, contusion and/or ataxia. Consider
potential additive effects with other hypnotics or CNS depres-
sants Employ usual precautions in severely depressed patients,
or in those with latent depression or suicidal tendencies, or in
those with impaired renal or hepatic (unction.
Adverse Reactions: Dizziness, drowsiness, lightheadedness.
staggering, ataxia and tailing have occurred, particularly in
elderly or debilitated patients. Severe sedation, lethargy, dis-
orientation and coma, probably indicative of drug intolerance or
overdosage, have been reported. Also reported: headache,
heartburn, upset stomach, nausea, vomiting, diarrhea, constipa-
tion. Gl pain, nervousness, talkativeness, apprehension, irrita-
bility. weakness, palpitations, chest pains, body and joint pains
and GU complaints. There have also been rare occurrences ol
leukopenia, granulocytopenia, sweating, flushes, difficulty in
focusing, blurred vision, burning eyes, faintness, hypotension,
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speech, confusion, restlessness, hallucinations, and elevated
SGOT, SGPT. total and direct bilirubins, and alkaline phospha-
tase; and paradoxical reactions, e.g., excitement, stimulation
and hyperactivity.
Dosage: Individualize for maximum beneficial effect. Adults.
30 mg usual dosage; 15 mg may suffice in some patients.
Elderly or debilitated patients: 1 5 mg recommended initially
until response is determined.
Supplied: Capsules containing 15 mg or 30 mg flurazepam HCI.
Roche Products Inc.
Manati, Puerto Rico 00701
. . . alone.
We’re 6,900 New Jersey physicians
insuring ourselves through our own
non-profit company. If you haven’t
joined us, you could be more at risk
than you know. You owe it to
yourself — and those that depend on
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Two Princess Road, Lawrenceville, NJ 0864f
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370
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
Editorial
Physicians in the
Mouse Trap
Leon G. Smith, m.d.
Physicians must plan and work
together. Be involved and address
problems before we are legislated to
death. The mouse trap is set.
D
uring the past decade we have
witnessed the greatest revol-
ution in medical history. There
ave been achievements well beyond our most imag-
lative dreams. Drugs (cardiac and antibiotics), de-
ices (computed tomography and nuclear magnetic
^sonance), and procedures (endoscopy and angioplas-
r) all have added new dimensions to patient care,
nfortunately, these achievements have accelerated
bor costs of medical care astronomically. Intensive
ire which is daily care with continuous monitoring,
ad one-to-one nursing along with aggressive medical
itervention have placed costs at some centers at well
/er $1,000 per day, per intensive care unit.
To cope with these new sets of events, our govem-
lent has devised new control measures geared to pre-
snt the reoccurrence of the rapid rise of costs. Their
rst attempt has been to contain hospital costs. The
RG (diagnostically related group) system has been
nployed even though “it has not been a system
roven beyond the shadow of doubt.” This typifies the
nse of urgency of our already overtaxed medical sys-
'm. It is estimated that 1,000 of the hospitals in the
nited States will close in the next year.
As we begin to adjust to this new DRG system, we
lust be made aware of the next phase of cost contain-
ment in the medical profession and its allied fields. The
ext government attack will be multifaceted. First and
iremost, there presently exists a surplus, not only of
octors and dentists, but of podiatrists, optometrists,
liropractors, midwives, and psychologists, all of
3L. 81— NUMBER 5— MAY 1984
whom will be competing for the “shrinking dollar."
What can we look forward to and how should we re-
spond to the coming events?
Most notably, we shall witness creative efforts by
doctors to attract new patients. Emergency centers,
“no appointment needed” office hours, advertisement
gimmicks, and new marketing approaches already are
upon us. Staff doctors of the larger hospitals literally
are fighting for emergency room rotations to ensure
more patients. There is a growing demand for limi-
tations of privileges in doing procedures such as co-
lonoscopy and bronchoscopy. Hospitals are plagued
with unending demands for the lucrative readings of
EKGs and echocardiograms. Specialists are beginning
to redefine their domains. Radiologists utilizing the
computed tomography (CT) scan also are biopsying
lung lesions while, at the same time, pulmonary
specialists in the field of internal medicine are
challenging the monopoly of radiologists who receive
exclusive fees for interpreting CT scans of the lungs.
Vascular surgeons resent the intrusion of radiologists
in performing angioplasty. The new specialty in in-
tensive medicine has been inhibited by pulmon-
ologists, anesthesiologists, and gastroenterologists be-
cause the intensivist can do all of their procedures
with equal skill. Cardiologists demand that all patients
in the cardiac care unit obtain a consultation from a
board certified cardiologist. Cardiac catheterization
physicians vie with cardiac surgeons to insert
pacemakers. Some hospitals have closed their medical
staffs. Renal dialysis groups have discouraged young
nephrologists from participating in their decreasing
prosperity. Laser instrument use is restricted to a
select few under the guise that excellence must be
achieved by one before it can be transmitted to others.
While all of this is going on, the costs of malpractice
insurance, medical school tuition, and office overhead
continue to climb. Also, there is a growing body of
newcomers called “medical whores.” They are doctors
who will testify against other doctors in the courtroom
even under oath regardless of the truth. These greedy
ones are driven in part because of exorbitant financial
needs. Often, the young doctor is enormously in debt
from educational expenses that he now must repay.
With new antibiotics like ceftriaxone, which has
prolonged half-life, more patients with long-term hos-
pitalization due to osteomyelitis, cellulitis, and en-
docarditis now can be treated as outpatients; this re-
moves “chunks" of the physician’s revenue for daily
inpatient care. New corporations have sprung up all
over the country providing total home health care. This
venture further decreases hospital and physician care
and revenue.
What shall be the net effect of these changes? There
is little question but that doctors will have to settle for
less income and a simpler way of life. Overhead ex-
penses must be curtailed and a more careful search
for the best place to start practice will be a must. My
concern is that doctors by nature are rather narrow-
minded, unimaginative people with chronic "free-float-
ing” anxieties and, hence, may fixate on these major
problems rather than pursue knowledge and excel-
lence through education and teaching. I have noticed
that physicians’ attendance at grand rounds has de-
creased; free clinics participation is a rarity: and sur-
371
geons, on rare occasions, have transferred emergency
cases to university and city hospital house staff rather
than operate without a fee. There are fewer medical
teachers and researchers.
I fear that the economics of medicine will control
every aspect of our lives. If we do not maintain the
dignity which we inherited from the dedicated phy-
sicians who came before us, then we have lost every-
thing that is important in this life. The increasing
preoccupation of physicians with business matters is
not a healthy sign. Ironically, the students of the
1960s, who had soft lofty ideals, will be faced with
medicine’s greatest challenge. Optimistically, 1 predict
that from all of this will emerge a new system: more
efficient, far more govemmentally regulated, and more
competitive. Will it prevent the transfer of ill patients
to a better facility? Will it shut out the newly trained
physician? Will it impose political restraints on allied
medical groups? Will the medical profession continue
to receive the “god like” respect held for them by the
people?
I personally challenge each in the medical field to
begin to think anew, to develop new plans, to work
together, to curtail waste, and to reflect upon our new
role in these changing times. Let us consider the fol
lowing commandments:
1. There should be compromise between specialists
without jeopardizing quality in the area of procedura
domain. This will not be easy.
2. Monopolies and narrow lines of disciplines musi
be eliminated.
3. We must plan and work together. If tensior
heightens, as it shall in stress, then our emotions wil
prevent rational solutions. I implore eveiy physician ir
America to communicate now with your government
Become involved and address these problems before w<
are legislated to death by an incompetent, ignorant
and rigid bureaucracy. A passive role will lead to disas
ter, with physician fighting physician, with variou:
medical ethnic groups banding together, and with th<
laity demanding a new system. The mouse trap is set
Before we all become victims of our own greed, shal
we run for the cheese or shall we jam the spring? Th«i
choice still is ours but not for long. Shall our choicii
be imaginative planning and working together now o
shall it be our crying out to legislators to free us frorr
the trap? The latter will cast us into a maze calleij
socialized medicine.
I
372
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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3L. 81— NUMBER 5— MAY 1984
373
Benefits diuretics cannot offer . . .Once-daily inderal la
(propranolol HC1) provides smooth, 24-hour control of blood pressure
plus the cardiovascular benefits of the world’s leading beta blocker.
And INDERAL LA provides a high degree of patient acceptance—
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Experience no other beta blocker can match.. . Once daily
INDERAL LA delivers the proven performance and safety profile of
INDERAL tablets— confirmed by millions of patients during 16 years
of clinical use. INDERAL LA should not be used in congestive heart
failure, sinus bradycardia, heart block greater than first degree, or
bronchial asthma.
Start with 80 mg once deity, . . Dosage may be increased to
120 mg or 160 mg once daily as needed to achieve additional control.
Please see next page for further details and brief summary of
prescribing information.
80 120 160
mg mg mg
The appearance of INDERAL LA capsules
is a registered trademark ot Ayerst Laboratories.
Ayerst
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
80 120 160
mg mg mg
i 'quirement ot me heart ai
Imceases igthe heflf rate,
(ratal &riiractton. Propffinolol
lar liber .lenglfr’SKsBlstolic
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL" LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially,
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically eguivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain Although total peripheral
resistance may increase initially, it read|usts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and somewhat variable INDERAL has
been shown to cause a small increase in serum potassijc(pconcentration when usecjjj the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces ttjB|
any given level of ef fori by blocking the catecholamine W
systolic blood pressure, and the velocity and extent off
may increase oxygen requirements by increasing left m.
pressure and systolic election period The net physiologic < Meet of beta-adrencrgic SMtode
is usually advantageous and is manifested during ©tfercise-tiy dtefi-yed Onset of pain and
increased work capacity
In dosages greater than required for beta blockade. INDERAL also exerts a qumidme-
or anesthetic-like membrane action which affects the- cardiac action pole" t ai. fhe snif
cance of the membrane action in the treatment of i|f§}^fhrmas suf'Vif'ain. ' ' *
The mechanism of the antimigraine effect ol pro
adrenergic receptors have been demonstrated in f
Beta receptor blockade can be useful in cond
functional changes, sympathetic activity is defimefitai -to I
situations in which sympathetic stimulation is vital ^X^ampi^Tr patients wUffTseverely
damaged heads, adequate ventricular function is maintained by vidue of sympathetic drive
which should be preserved In the presence of AV block, greater than lirst degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interiermg with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypedension; it may be used alone or used in combination with other antihypedensive
agents, padicularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypedensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has staded has not been
established and propranolol is not indicated for such use
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypedrophic subaodic stenosis, especially for treatment of exedional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise pedormance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block, 3) bronchial asthma, 4) congestive head
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
podmg circulatory function in patients with congestive head failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
oved congestive head failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on head
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of head
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking theraj
prior to major surgery is controversial It should be noted, however, that the impaired ability i
the head to respond to reflex adrenergic stimuli may augment the risks of general anesthesi
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of beij
receptor agonists and its effects can be reversed by administration of such agents, e.il
dobutamine or isoproterenol. However, such patients may be subject to protracted sevej
hypotension. Difficulty in stading and maintaining the headbeat has also been repoded wi
D6t3 blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the a|
pearance of cedain premonitory signs and symptoms (pulse rate and pressure changes) i
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be mej
difficult to adjust the dosage of insulin
THYROTOXICOSIS Beta blockade may mask cedain clinical signs of hyperthyroidis!
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptor
of hypedhyroidism, including thyroid storm. Propranolol does not distod thyroid function tes
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have be
repoded in which, after propranolol, the tachycardia was replaced by a severe bradycarci
requiring a demand pacemaker In one case this resulted after an initial dose of 5 rj
propranolol
PRECAUTIONS. General: Propranolol should be used with caution in patients with impair
hepatic or renal function. INDERAL is not indicated for the treatment of hypertensij
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patieij
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal ml
lead to a return of increased intraocular pressure
Clinical Laboratory Tests Elevated blood urea levels in patients with severe head diseaij
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as res
pine should be closely observed if INDERAL is administered The added catecholamir
blocking action may produce an excessive reduction of resting sympathetic nervous activ
which may result in hypotension, marked bradycardia, vedigo. syncopal attacks, or odhosta
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals ha
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studies
^50 mg/kg/day. there was no evidence of signific.
plated tumongenic effects at any of the dosa
not show any impairment of fedility that w
\IDERAL has been shown to be embryotoxic
liter than the maximum recommended human do:
ffrblled studies in pregnant women INDERAL shoi
be used during pregnancy only if the potential benefit justifies the potential risk to the fetil
Nursing MoJjfs INDERAL is excreted in human milk Caution should be exercised wh
sie
I vygpian
ss in children have not been established
effects have been mild and transient and hel
ad failure, intensification of AV block, hyp!
Purpura, aderial insufficiency, usually of I1
IN PATIENTS WITH ANGINA PECTORIS, there have been repods of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic head disease who are given propranolol for other
indications.
Igensioi
‘TfaynaujnTpe*
Central Nervous SysferrarigBrneadedness, mental depression manifested by msomr!
lassitude, weakness, fatigute^Wversible mental depression progressing to catatonia, visi|
disturbances; hallucinations; an acute reversible syndrome characterized by disorientation
time and place, shod-term memory loss, emotional lability, slightly clouded sensorium, a;
decreased pedormance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhi
constipation, mesenteric aderial thrombosis, ischemic colitis
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with achij
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopeij
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has be
repoded
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imjl
tence, and Peyronie's disease have been repoded rarely. Oculomucocutaneous reactic;
involving the skin, serous membranes and conjunctivae repoded for a beta blocker (practo
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride i!
sustained-release capsule for administration once daily. If patients are switched from INDER
tablets to INDERAL LA capsules, care should be taken to assure that the desired theraper
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute:
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitration n
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inter'
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 il
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may
increased to 120 mg once daily or higher until adequate blood-pressure control is achiev
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage of f
mg may be required The time needed for full hypertensive response to a given dosagt
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL
once daily, dosage should be gradually increased at three to seven day intervals until optim
response is obtained Although individual patients may respond at any dosage level,
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value £
safety of dosage exceeding 320 mg per day have not been established.
If treatment is to be discontinued, reduce dosage gradually over a period of a few we<
(see WARNINGS)
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDERAL
once daily The usual effective dose range is 160-240 mg once daily. The dosage may:
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is :
obtained within four to six weeks after reaching the maximum dose, INDERAL LA then,
should be discontinued It may be advisable to withdraw the drug gradually over a perioc,
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group are
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laborator
8950/2
Nonaliergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N Y. 10017
376
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Selection of a Medical Office
Computer System
James W. Allen, m.d., river edge*
Selection of a computer system for an office requires
understanding of the computer marketplace as well as personal
needs. The computer marketplace has three distinct segments
offering different approaches to computerization. Functionality ,
support , and price summarize a physician’s computer needs.
No physician can ignore com-
puter advertisements in the
medical and lay press that claim
mtastic benefits at an amazingly wide range of prices,
hese benefits certainly would attract any cost-con-
:ious physician. Realizing these benefits, though, re-
uires addressing several issues. First, the doctor must
.am computer jargon. Only when you have mastered
jbrms like hardware (the computer itself), software
hat which makes the hardware operate), “byte” (one
naracter), and “mass storage devices” (such as floppy
r iscs or Winchester technology), can you describe sue-
?essfully your needs for automation. Next, the phy-
iCian must ensure that the office staff will support
j| Dmputerization. Finally, the doctor must leam from
ie horror stories told by colleagues who had unsuc-
cessful attempts at automation. Some doctors in-
efinitely postpone a decision to automate because of
aese issues. For those who do come to terms with
uese factors, the final decision becomes: which in-
ouse computer is “best” for the practice.
Like the decision to automate, the decision to
urehase can be exasperating. Only price seems to
differentiate vendors who offer seemingly similar com-
ater systems. The temptation is to choose a system
ased solely on price. I propose an alternate selection
lethod which looks at the characteristics of the corn-
ater marketplace as well as the individual praeti-
oner.
MEDICAL COMPUTER MARKETPLACE
Just as diabetic patients fall into categories such as
adult and juvenile onset, the vendor of medical com-
puter systems has definite characteristics. Some of
these differentiating characteristics are the distribu-
tion method, support provided, and system expand-
ibility (Figure 1). Using these characteristics, medical
vendors fall into the following categories: mail-order
companies and large distributor chains who sell soft-
ware for popular personal computers; vendors selling
business computers specially programmed for phy-
sician office automation; and local dealers or computer
consultants who provide specially tailored systems.
A physician can purchase medical office billing soft-
ware by mail-order or through an electronic dealer
network. This software usually requires the popular
Apple or Radio Shack computer along with one to three
disc drives for floppy disc storage. With the software
comes instructions on converting your present man-
ual accounting system to computerized system. Typi-
cally, neither the software vendor nor the hardware
supplier provides much individual support. Purchase
price is less than $10,000 for hardware and software.
Some vendors are developing special expertise in the
*Dr. Allen is a computer consultant and Instructor in Clinical
Pathology, Columbia University College of Physicians and
Surgeons, New York. Correspondence may be addressed to Dr.
Allen, 181 Jefferson Avenue, River Edge, NJ 07661.
OL. 81— NUMBER 5— MAY 1984
377
“vertical” market for medical systems. From these ven-
dors the physician purchases a complete system, both
hardware and software, as well as training, system
support, and site preparation. These vendors typically
use business computers such as IBM, ALTOS, Alpha
Micro, or DEC and use Winchester type hard disc. In
addition to medical accounting, these vendors can
supply enhanced software that will perform appoint-
ment scheduling, special report writing, word proc-
essing, diet analysis, and other functions. Price for the
basic system starts at about $20,000.
The final category in the computer marketplace is
local vendors or freelance programmers who will write
computer software to your specifications. You must
outline for them the specific task that you want ac-
complished. These vendors then can write the software
and select the hardware that is best suited to your
needs. Finding a good freelance programmer is dif-
ficult. Costs easily can mount due to programming
bugs and vague specifications.
PHYSICIANS’ NEEDS
Functionality, support, and price summarize a phy-
sician’s requirements for an office computer system.
The relative importance of each of these categories
depends on the physician’s practice and temperament.
Functionality implies the ability of the computer sys-
tem to meet present and near-term (two to five years)
requirements. Data storage capacity is very important
in satisfying the functionality requirement. To esti-
mate storage needs, you must determine the number
of bytes of data you expect to process. Figure 2 shows
some helpful guidelines. The total number of bytes
determines the type of mass storage device. Commonly
used storage devices are floppy discs, hard discs, and
Winchester technology drives. These devices are a sig-
nificant factor in the total hardware cost of a computer
system.
Other requirements contribute to the total func-
tionality of the system. Commonly forgotten is an ap-
preciation for:
• The number of different statements or insurance
forms to be completed, now and in the future;
• The likelihood that the system must perform mul-
tiple operations, such as printing and data input at the
same time (multitasking);
• The need for future enhancements, such as word
processing, dietary analysis, and spread sheet
capabilities;
• The possibility of communication between your
office system and another computer located in your
home or on a computer network;
• The ease with which the software can be custom-
ized to match the documents used in your practice.
Ely appreciating these requirements, you can better
define the true functionality of a computer system in
your office in addition to storage capacity.
In establishing your support requirements you must
ask yourself questions on your needs for training and
documentation, system reliability, and service avail-
ability. Vendors provide training programs (on or off
site), and support through telephone linkages. The
level of staff interest and the staff turnover rates will
determine how much of these services you will need.
Mail-Order Distributors, Mass Distributors
• Purchaser installs system
• Dedicated to one task, i.e. billing or word processing
• Limited system support
• Relatively small data storage capability
Vendors Dedicated To Supplying Physician Office Systems
• Installation and training provided
• Expandable to numerous tasks
• Complete system support
• Wide range of data storage capabilities
Specially Tailored Systems
• Matches your specific needs
Figure 1— Characteristics of the medical computer market-
place.
Per Patient Estimates
Name and address
200 Bytes
Financial/insurance
2000 Bytes
Medical/prescription
2000 Bytes
Per physician estimate
4,000,000 Bytes
Example: An estimate of storage requirements for name,
address, and financial/insurance data on 10,000 patients |
is 22,000,000 bytes (10.000 x 200 + 10,000 x 2,000)
Figure 2 — Guidelines for determining data storage require-
ments.
Obviously, a practice with high turnover in staff will
require more training and support than one with a
stable staff. System reliability and vendor responsive-
ness to service requests also are important aspects of
your support requirement. Several steps can help you
access these requirements. First, visit a colleague with
a system similar to the one you are contemplating
purchasing. Just observing the system’s operation will
answer many questions. Then, ask yourself these ad-
ditional questions: flow long could my system be down
without hurting the practice? Will dealing with mul- (
tiple vendors for hardware and software support cause !
me inconvenience? What ties does my practice have to
a computer service organization? Improper assess- r
ment of the support requirements accounts for many
of the horror stories you hear about medical office
computer systems.
Price limitations are a requirement all of us must'
face when making major purchases. Three prices are
important in a computer purchase: acquisition costs,
operating expenses, and enhancement fees (Figure 3).
Computer equipment qualifies for both investment tax
credit and depreciation expense, so your out-of-pocket
costs may be less than the stated purchase price. Many
computer vendors provide an equipment leasing op-
tion to reduce large capital outlays. Remember to in
elude in the price of the system the costs for site prep-!
aration, such as electrical and carpentry work, power
conditioners, antistatic mate, shipping charges, and
other necessities. Operating expenses for a computer
system include costs of paper, supplies, and vendor
support. With a computerized system each physician
uses approximately $4,000 of paper products per year
j ::
378
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Acquisition Cost Options
• Purchase price reduced by investment tax credit and
depreciation expense
• Lease
nstallation and Site Preparation Costs
• Electrical and carpentry work
• Shipping
• Antistatic mats
• Power stabilizers
Operational Expenses
• Paper and supplies — 3 percent per month or $4,000
per physician per year
• Vendor-support contract— 1 to 2 percent per month
Enhancement Fees (cost of common enhancements)
• Word processing
• Dietary analysis
• Spread, sheet capabilities
jure 3 — Considerations in price comparison.
A
l a monthly basis these consumable supplies rep-
sent about 3 percent of total system purchase price.
Id to this the monthly cost of vendor support, typi-
lly 1 to 2 percent of the total purchase price. As part
this support contract, most vendors will supply new
eases, i.e. modifications of existing programs, at no
iditional charge. However, if you plan to enhance the
pability of your system, such as adding word proc-
sing, then plan on paying for this enhancement.
' edless to say, in defining your price requirements
ijnsult your tax advisor and accountant.
l )MPUTER SELECTION PROCESS
As an alternative to comparing systems solely on the
I sis of price, our selection process involves two steps.
Irst, the physician evaluates the functional needs,
: pport requirements, and price limitation of the prac-
e. Then, the physician identifies the market segment
ipst likely to meet those needs. Several cases will il-
Istrate this selection process in action.
Case 1: Growing practice in a major metropolitan
£ 5a with much third-party billing. Requirements: The
i mediate needs are for third-party billing and rec-
( ^keeping; however, the group expressed strong
i :erest in an appointment scheduling system as well
£ recording of patient clinical data. The large size of
fs practice indicates a large volume of reports with
£ ieed for multiple terminals, each performing a dif-
f ent function. None of the physicians have special
i erest in computing. Office staff positions are stable,
E:ept for clerical personnel who most frequently
v uld use the terminal. Financial analysis shows that
S 0,000 is the maximum cash outlay available for the
System. Recommendations: This practice should
f rchase a complete system from a vendor specializing
i medical computing. Factors influencing this rec-
cimendation are the multitask requirements, low
1 el of inhouse computer experience, heavy computer
workload, and system expansion requirements. Be-
cause of the practice location, a variety of system ven-
dors will have local sales and support organizations.
Case 2: Older solo practitioner who requires patient
billing capability. Requirements: This physician has
been in practice at the same location for many years.
As a result, the practice has strong ties with local
merchants including the manager of a consumer elec-
tronics store. Because most patients pay in full after
each visit, the doctor's billing requirements are not
large. The office staff is very stable and very
enthusiastic about a computer. Recommendations: An
enthusiastic staff and close ties to a computer dealer
suggest that this practice could generate much
internal computer support. In addition, the practi-
tioner’s small practice size and limited computer needs
do not require large computer capability. In this situ-
ation the physician should choose software that can
be implemented on a popular personal computer.
Case 3: Two-man practice with one partner having
definite computer interests. Requirements: As a result
of college training and much personal interest, one
partner has become quite skilled in computer pro-
gramming. He envisions a system that records basic
patient demographic data progress notes, and ac-
counting records. Already, he has completed some of
the programming for the system. His partner also is
veiy enthusiastic about the proposed system. Rec-
ommendations: Probably no commercially available
system will satisfy these physicians. Before starting to
create their own system, they should be cautioned
against "reinventing the wheel.” A good approach is to
customize an existing system for their specific needs.
These physicians probably are well aware of the need
for definite specifications and the high cost of free-
lance programmers. If the partners properly direct pro-
grammers, they will have a system exactly tailored to
their needs.
YOUR COMPUTER DECISION
This article may help you to appreciate the segmen-
tation of the marketplace for medical computer sys-
tems. Each segment offers a different approach to your
data processing needs. You best can understand your
own unique needs by describing your requirements in
terms of functionality, service, and support. The rec-
ommended readings will help in your requirements
definition. My approach to system selection is to apply
your requirements to that market segment most likely
to meet your needs. Failure to make comparisons of
vendors within market segments is like choosing be-
tween apples and oranges based only on price.
REFERENCES
1. Auer J, Harris C: Computer Contract Negotiations. New
York, NY, Van Nostrand Reinhold Company, 1981.
2. Cohodes S: Computer boosts monthly collections by 35
percent. Physician's Management. 137-141, 1981.
3. Enlander D: Computers in Medicine. An Introduction.
St. Louis, MO, C. V. Mosby Company, 1980.
4. Shaw DR- Your Small Business Computer. New York.
NY, Van Nostrand Reinhold Company, 1981.
If
L. 81
—NUMBER
5— MAY 1984
379
WHYo
Through the AMA .«**!
immediate acce t onom-
medioat. wenttc. a maintains a
icintormation.The^rarv sand
tetgecolleettw^^rton.Hne
microtilm and P ov0 information
access to ^^^.erized data
sources ,hr°“9Nbrary; it's one more
^r-V^sU-ddeapar,
01 the AMA.
To J©*n» . . nr state medical
Contact V°ur ““Division of Member-
society or Dearborn Street,
606101 °rca"co"ect'
(312)751-6196.
References:
1 . Stone PH, TuriZG, Muller JE Efficacy of nifedipine therapy for refractory angina
pectoris Am Heart J 104 672-681, September 1982
2. Antman E, Muller J, Goldberg S, et al Nifedipine therapy for coronary-artery
spasm Experience in 127 patients N Engl J Med 302 :1269-1273, June 5, 1980
BRIEF SUMMARY
PROCARDIA " (nifedipine) CAPSULES For Oral Use
INDICATIONS AND USAGE: I Vasospastic Angina: PROCARDIA (nifedipine) is indicated for the
management ot vasospastic angina confirmed by any of the following criteria: 1 ) classical pattern
of angina at rest accompanied by ST segment elevation, 2) angina or coronary artery spasm pro-
voked by ergonovme, or 3) angiographically demonstrated coronary artery spasm In those patients
who have had angiography, the presence of significant fixed obstructive disease is not incompatible
with the diagnosis of vasospastic angina , provided that the above criteria are satisfied , PROCARDIA
may also be used where the clinical presentation suggests a possible vasospastic component but
where vasospasm has not been confirmed, eg. where pain has a variable threshold on exertion or
in unstable angina where electrocardiographic findings are compatible with intermittent vaso-
spasm, or when angina is refractory to nitrates and/or adeguate doses of beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated for
the management of chronic stable angina (effort-associated angina) without evidence of vasospasm
in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrates
or who cannot tolerate those agents.
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controlled
trials of up to eight weeks duration in reducing angina frequency and increasing exercise tolerance,
but confirmation of sustained effectiveness and evaluation of long-term safety in those patients are
incomplete
Controlled studies in small numbers ot patients suggest concomitant use of PROCARDIA and
beta blocking agents may be beneficial in patients with chronic stable angina, but available infor-
mation is not sufficient to predict with confidence the effects of concurrent treatment, especially in
patients with compromised left ventricular function or cardiac conduction abnormalities When in-
troducing such concomitant therapy, care must be taken to monitor blood pressure closely since
severe hypotension can occur from the combined effects of the drugs (See Warnings )
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect ol
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol-
erated hypotension These responses have usually occurred during initial titration or at the time o‘
subsequent upward dosage adjustment, and may be more likely in patients on concomitant beta
blockers
Severe hypotension and/or increased fluid volume requirements have been reported in patient;
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypass
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to be
due to the combination ot PROCARDIA and a beta blocker, but the possibility that it may occur with
PROCARDIA alone, with low doses ot fentanyl, in other surgical procedures, or with other narcotic
analgesics cannot be ruled out In PROCARDIA treated patients where surgery using high dost
fentanyl anesthesia is contemplated , the physician should be aware of these potential problems and
it the patient's condition permits, sufficient time (at least 36 hours) should be allowed fo
PROCARDIA to be washed out of the body prior to surgery
Increased Angina: Occasional patients have developed well documented increased frequency, du
ration or severity ot angina on starting PROCARDIA or at the time of dosage increases. The mech
amsm of this response is not established but could result from decreased coronary perfusior
associated with decreased diastolic pressure with increased heart rate, or from increased demant
resulting from increased heart rate alone
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with
drawal syndrome with increased angina, probably related to increased sensitivity to catechol
amines. Initiation of PROCARDIA treatment will not prevent this occurrence and might be expedet
to exacerbate it by provoking reflex catecholamine release There have been occasional reports o
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation It is importan
to taper beta blockers if possible, rather than stopping them abruptly before begmnini
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed hear
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater riskfo
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascula
resistance, careful monitoring of blood pressure during the initial administration and titratio
of PROCARDIA is suggested Close observation is especially recommended for patients alread
taking medications that.are known to lower blood pressure (See Warnings )
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso
dilation and not due to left ventricular dysfunction, occurs in about one in ten patients treated wit
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diureti
therapy With patients whose angina is complicated by congestive heart failure, care should be take
to differentiate this peripheral edema from the effects of increasing leff ventricular dysfunction.
Drug interactions: Beta-adrenergic blocking agents: (See Indications and Warnings ) Expenem
in over 1400 patients in a non-comparative clinical trial has shown that concomitant administratio
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasion;
literature reports suggesting that the combination may increase the likelihood of congestive heai
failure, severe hypotension or exacerbation of angina
Long-acting nitrates: PROCARDIA may be safely co-admmistered with nitrates, but there ha'
been no controlled studies to evaluate the antianginal effectiveness of this combination.
Digitalis: Administration of PROCARDIA with digoxm increased digoxm levels in nine of twef
normal volunteers The average increase was 45%. Another investigator found no increase in d|
goxm levels in thirteen patients with coronary artery disease In an uncontrolled study of overt'
hundred patients with congestive heart failure during which digoxm blood levels were not mea:
ured. digitalis toxicity was not observed Since there have been isolated reports of patients will
elevated digoxm levels, it is recommended that digoxm levels be monitored when initiating, adjusf
mg, and discontinuing PROCARDIA to avoid possible over- or under-digitalization
Carcinogenesis, mutagenesis, impairment of fertility When given to rats prior to mating, nifi
dipine caused reduced fertility at a dose approximately 30 times the maximum recommended hij
man dose
Pregnancy: Category C Please see full prescribing information with reference to teratogenicity
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys
ADVERSE REACTIONS: The most common adverse events include dizziness or liaht-headednes
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of pj
tients, transient hypotension in about 5%. palpitation in about 2% and syncope in about 0.5°.
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antia
ginal medication Additionally, the following have been reported muscle cramps, nervousnes
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shal
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus, urticaria, I
ver, sweating, chills, and sexual difficulties Very rarely, introduction of PROCARDIA therapy w
associated with an increase in anginal pain, possibly due to associated hypotension
In addition , more serious adverse events were observed, not readily distinguishable from the n;i
ural history of the disease in these patients. It remains possible, however, that some or many
these events were drug related Myocardial infarction occurred in about 4% of patients and conge'
tive heart failure or pulmonary edema in about 2% Ventricular arrhythmias or conduction distur
ances each occurred in fewer than 0 5% of patients
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline phc
phatase, CPK, LDH, SGOT, and SGPT have been noted, and a single incident of significantly e
vated transaminases and alkaline phosphatase was seen in a patient with a history of gall blade
disease after about eleven months of nifedipine therapy The relationship to PROCARDIA therapy
uncertain These laboratory abnormalities have rarely been associated with clinical symptorr
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive wo
literature
HOW SUPPLIED: Each orange, soft gelatin PROCARDIA CAPSULE contains 10 mg of mfedipi
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069-2600-66). 300 (NDC 006
2600-72), and unit dose (10x10) (NDC 0069-2600-41) The capsules should be protected frej
light and moisture and stored at controlled room temperature 59° to 77°F ( 15° to 25°C) in the m;;
ufacturer's original container.
More detailed professional information available on request © 1982, Pfizerli
LABORATORIES DIVISION
PFIZER INC
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS/
380
Quotes from an unsolicited '
letter received by Pfizer from an
angina patient.
While this patient 's experience
is representative of many I
unsolicited comments received,
hot all patients will respond to
Procardia nor will they all
respond to the same degree -
)> 1983, Rizer Inc.
7 have been able to do volunteer
work. . . and feel needed and useful
once again."
"My daily routine consisted of
sitting in my chair trying to stay alive."
"I shop, cook and can plant
flowers again."
"My doctor switched me to
PROCARDIAM as soon as it became
available. The change in my condition
is remarkable."
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again.
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0 5%).
for the varied faces of angina
Procardia is indicated for the management of:
1 ) Confirmed vasospastic angina.
2) Angina where the clinical presentation suggests a possible
vasospastic component
3) Chronic stable angina without evidence of vasospasm in
patients who remain symptomatic despite adequate doses of
beta blockers and/or nitrates or who cannot tolerate these
agents. In chronic stable angina (effort-associated angina)
PROCARDIA has been effective in controlled trials of up to
(eight weeks’ duration in reducing angina frequency and
increasing exercise tolerance, but confirmation of sustained
effectiveness and evaluation of long-term safety in these
'patients are incomplete.
;OL. 81— NUMBER 5— MAY 1984
I
PROCARDIA
(NIFEDIPINE)'
Please see PROCARDIA brief summary on ad/oining page.
381
Our reputation has
been built on our
SERVICE
JMK AUTO SALES
391 Rt. 22 (East) Springfield, New Jersey
379-7744
The Psychological Impact of Cancer
on Patient and Family
Barton A. Singer, ph.d., cherry hill*
The psychological impact of cancer on the patient and the family
almost can be as traumatic as the physical effects. Patient and
family must deal with marked changes in the family structure and
feelings of isolation, loneliness, helplessness, and dependence.
Denial, isolation of affect, and rationalization are discussed.
The psychological impact of
cancer on the patient and the
family almost can be as trau-
matic as the physical effects. Realistic as well as un-
realistic stresses and fears are aroused which can over-
whelm the individuals who have to cope with them. To
|be faced with the anticipation of dying from cancer
with all the connotations and implications that usually
are associated with this illness, is to be struck with
ane of the ultimate painful emotional events in life.
However, because it is human nature to try to avoid
ithe experience of pain as much as possible, it often is
extremely difficult for cancer patients and their fami-
lies to relate to each other and deal with their problems
in a constructive way. Psychological defense mecha-
nisms are utilized to an excessive degree in order to
keep threatening thoughts and feelings from con-
scious awareness and from overwhelming the individ-
ual. Consequently, important personal issues are not
dealt with so that tensions and conflicts among family
members usually are increased.
PSYCHOLOGICAL CONSEQUENCES
OF THE ILLNESS
Psychological stresses facing families with members
who have cancer have been described at length in the
iterature.1 578 The intense physical pain of the illness
ind/or the treatment, the difficulty in accepting that
one’s life soon is to end, the helplessness and inability
VOL. 81— NUMBER 5— MAY 1984
to do much for oneself to influence the disease, the
uncertainty of treatment outcome, the physical
changes in one’s body, the catastrophic financial
burden, and the alterations in family patterns and
roles are all consequences of the illness that cannot be
avoided to any great extent. Adding to these realistic
hardships, however, are those that are brought about
by the individual’s unadaptive coping mechanisms
which exacerbate a terrible situation. When certain
aspects of reality are distorted or ignored and when
expected and understandable feelings are part of the
family atmosphere but not recognized and talked
about, conflicts fester and hardships are magnified.
For example, the impending death of a parent usually
necessitates modifications in the family structure that
should be planned for and discussed. Role changes are
required. The working husband may have to become
more responsible for child care and homemaking
duties. A wife who has been used to having her hus-
band handle the finances must become familiar with
economic realities. Often the children are not able to
continue participating in certain activities because no
one is there to transport them or there may not be the
necessaiy funds to pay for them. These deprivations
especially are hard for many children to accept because
*Dr. Singer is a clinical psychologist in private practice in
Cheriy Hill. Correspondence may be addressed to Dr. Singer,
Executive Mews, D-19, 1930 E. Marlton Pike, Cherry Hill. NJ
08003.
383
they often are left out of important family discussions
and they do not have a clear idea about the problem
facing everyone. Most family members have a natural
resentment toward these changes to some extent. If
these negative feelings are not recognized and under-
stood, however, the anger felt towards a sick loved one
can stir up so much guilt and increased resentment
that constructive readjustments almost are impossible
to make.
For example, a patient was told that he had about
two years to live. An industrious, hard-working, overly
independent man, he had been the traditional sole
provider who assumed complete control of the family
financial situation. Because his wife accepted her con-
ventional role so completely, this aspect of their rela-
tionship had not caused any apparent difficulty until
the illness was diagnosed. At that time, she realistically
started to woriy about their income and financial re-
sources and asked her husband systematically to re-
cord their assets so that she would have an accurate
appraisal of the situation. For one year, her husband
said he was going to comply but he never was able to
complete the task. To do what was required, would be
to admit to himself that he would be dying soon. Con-
sequently, he continued to deny the necessity of com-
pleting the record, rationalizing that he still had plenty
of time. Often, he repressed the project until his wife
mentioned it again, at which time he would become
very irritated and accuse her of nagging. While he
could say that it made sense to do what she wanted
in order to relieve her anxiety and her uncertainty, he
could not bring himself to do it; this significantly in-
creased the tension between the couple.
Denial usually is considered
a primitive defense because
it often can bring about a
significant and dangerous
distortion of reality.
Feelings of isolation and loneliness typically are ex-
perienced by the patient with cancer, brought about
in part by the realities of the illness. Many families
spend inordinate amounts of time away from other
healthy people. Going to hospitals and undergoing
treatments take up so much time and energy that
there is little left over for socializing. Furthermore,
some healthy people tend to shy away from the criti-
cally ill and feel uncomfortable when patients talk
about their illness. Adding to the situation, however,
is the patients’ and the families’ reluctance to think
about and talk about certain unpleasant aspects of
their predicament. Often, what is foremost on the pa-
tient’s mind is some serious and depressing complica-
tion related to his sickness. No one wants to discuss
it. Yet, it is hard to find something else to talk about;
everyone in the house keeps quiet or searches for
something “pleasant" to say. Because the patient is not
able to express freely what really concerns him, he
often feels that no one understands or cares about
him, which increases his sense of isolation.
During the course of the disease the patient typically'
becomes weakened, helpless, and dependent on others.
The patient is not able to work as effectively as before.
Help from others is required. But the patient may be
reluctant to accept the fact that assistance is neces- •
sary. Dependency can be denied so long that it often
is very difficult to bring about the necessary readjust-
ments.
One patient, a compulsive homemaker, saw herself!
as the mainstay of the home. All decisions were made!
by her and all family activities were initiated by her.
After a mastectomy, she pushed herself to maintain a)
facade of normalcy, exhausting herself by an excessive i
effort to keep the house clean, care for the children,
drive them to activities, and work part time. While she
could not fully admit to herself that she had slowed
down, she did resent her family's inability or unwilling-
ness to detect her gradual decline and offer to help her.
By the time she finally had reached her limit and asked
for help, she was bitter and resentful. But her husband^
and children found it hard to understand her situation
and resented how and what she requested; she did not
look sick. Why couldn’t she continue to do what she
always had done? For an unfortunately long time, hen
husband directly refused to do household tasks; that! 1
was not part of his role definition as husband and
father.
DEFENSE STRATEGIES IN THE CANCER FAMILY
When defense mechanisms distort reality and hide
feelings, the individual cannot cope with significant
interpersonal difficulties in the most adaptive way.
And because the painful feelings, thoughts, and events d
associated with cancer are so traumatic and devastate
ing, the utilization of defenses particularly is excessive! <
and pervasive in this clinical population. Furthermore,
defensiveness between members of the family charac-
teristically is higher than with other people; intense,:
deeply personal familial relationships often are com-
plicated by long-standing unresolved conflicts and
family members frequently are reluctant to be frank
and open with their spouses or children. People typi-
cally fear that if they are more direct in communicating
their concerns, pains, and needs they will be rejected!
or they will upset the loved one. Therefore, it is easier
to talk more honestly with a neutral professional than;
with a relative.
One of the more prominent defenses seen in the
cancer patient is denial, which involves denying or
negating facts and feelings that would be painful tc
acknowledge; the person believes that he has no aware
ness of or responsibility for an event or feeling thali
actually exists. Denial usually is manifested in the re
versal of a painful fact, e.g. “I’m not so sick” When cjl
patient denies that he has any problems, it is hard tc
help him. This particularly is dangerous for the cancel '
patient where life can be endangered. A woman whc
feels a lump in her breast and says to herself, “It is
nothing,” does nothing about it. A young married mar
with a brain tumor has a great need to emphasize tha
he still can do most of the things that he used to ac
before his illness, like ride a bike in traffic or jog. I
still is hard for him to accept his limitations; he mus;
continue to deny many aspects of his declining con
dition.
384
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Denial usually is considered a primitive defense be-
use it often can bring about a significant and
mgerous distortion of reality. At times, however, it
50 can be an adaptive healthy maneuver; most pa-
>nts have to deny some aspects of their circumstance
certain junctures in the course of their illness in
der to reduce the impact of the traumatic event. One
nnot face death all the time. This defense helps the
tient to carry on with life and to do what living one
able to do. Consequently, the doctor and relatives
ed to respect denial and not push the patient to
cept the reality of his illness any faster than he is
lling and/or able to. While many patients do want
know the facts about their sickness, some do not
d they can deteriorate emotionally and physically
len they are informed too bluntly. It takes consider-
le psychological sensitivity to deal with denial effec-
ely and to present “the facts” in a therapeutic way.
A more efficient defense mechanism than denial is
ilation of affect. When this defense is operating, the
nnection between ideas and feelings are severed so
at the person is calm in a situation where strong
lotion would be appropriate and expected. With
>lation, patients can talk with equanimity about
tentially disturbing subjects like their impending
ath or the excruciating pain. Unfortunately, how-
?r, isolation can prevent them from coming into im-
'diate contact with their feelings in order to express
;m and then be relieved of some of their impact.
The following is an example of how isolation of affect
|.s therapeutically reduced in a treatment situation:
: eenage boy explained that, although he knew his
iher was very sick, he was not able to get in touch
tjth his feelings about this fact. It took him a long time
lusciously to become aware of the warded off feelings
i|d to be able to ciy and to talk to his father openly
put his dread and his fears of what life would be like
!|ien he is gone. Before this time, he felt unable to
'ate to him and to help him. He usually kept his
tance from his father and kept his thoughts to
nself.
Another prevalent defense manifested in the family
) cancer patients is rationalization. This mechanism
nsists of explaining away and trying to justify
oughts or a course of action by finding an excuse
f support a point of view that is more acceptable than
i ‘ real reason.6 Usually the rationalization takes the
«m of “false altruism.” One family member keeps
3 nful information from another in order to avoid
] posing a burden, something that could not be en-
Ired. Spouses hesitate to inform the patient about
i dical developments, patients do not want to discuss
- tain problems with their spouses, and most parents
d their children are too young to comprehend,
or example, a patient was reluctant to talk about
diagnosis with his teenage son even though he
cussed it with many other relatives. The son knew
)ut it because he was at the hospital when the fam-
il first was informed. Yet the father stated that he was
young to be encumbered with such horrible news
Ing: “He would not really understand.” Further-
n re, even when the patient was enduring excruciat-
k; pain and was so depressed that he felt he could
go on living, he held back tears because he did not
*]nt his wife to find out how depressed he was. He
feared that she would get more upset and frightened.
In most cases these kinds of rationalizations are
excuses which serve as a means to protect individuals
from becoming more completely and directly aware of
the painful feelings that they are strenuously tiying to
hide from themselves. Such individuals do not want
to deal with the unpleasant issue, so they tell them-
selves that they are avoiding it out of concern for the
other person.
Because of this excessive defensiveness, feelings are
cut off from conscious awareness. Consequently,
closer, more effective, and spontaneous communica-
tion is inhibited and certain aspects of reality are dis-
torted and not dealt with adaptively. Furthermore,
when defense mechanisms against becoming aware of
unpleasant feelings are operating to a pathological ex-
tent, it is difficult for the individual to integrate and
modulate them. These affects remain unconscious but
active and powerful in affecting one’s behavior. In
order to work through and accept the anger, sadness,
and loss and in order to mourn the psychological and
physical deprivations, the cancer patient and the fam-
ily have to become aware of the emotional events ex-
perienced, accept the feelings, and express them. This
usually results in some relief from their impact. But
because of their excessive utilization of defense
strategies, this psychological task is hard for these
patients to accomplish on their own. Some pro-
fessional help often is required to assist the family in
not avoiding issues that must be faced.
Particularly for this clinical population where there
is so much emotional pain to defend against and
where defensiveness is increased because of the family
atmosphere, counseling can be valuable. It allows fam-
ilies to focus on and deal more adaptively with trau-
matically threatening feelings and conflicts which,
when present but unacknowledged and avoided, create
massive blocks in communication, impasses which
add a further burden to an already intolerable situ-
ation. While the patient with cancer clearly benefits
from participation in counseling, it may be the family
members who gain the most. Obviously, they are the
ones who live longer and can continue to carry the
burden of guilt and unresolved mourning for a long
time. The death of a loved one often stirs up old con-
flicts and resentments. Helping them to deal realistical-
ly with the illness, accept death, and go on to live their
lives unencumbered by neurotically conflicting feel-
ings may be the most significant treatment goal.
REFERENCES
1. Bowers M, Jackson E, Knight J, LeShan L: Counseling
the Dying. San Francisco, CA Harper & Row, 1981.
2. Eissler K The Psychiatrist and the Dying Patient New
York, NY, International Universities Press, 1955.
3. Giacquinta B: Helping families face the crisis of cancer.
Am J Nursing 18:1585-1588, 1977.
4. Hackett TP: Psychological assistance for the dying pa-
tient and his family. Ann Rev Med 27:371-378, 1976.
5. Kubler-Ross E: On Death and Dying. New York NY,
Macmillan Publishing Co., 1969.
6. Laughlin HP: The Neuroses. Washington, D.C., But-
terworths, 1967.
7. Pineus L: Death and the Family. New York NY, Random
House, 1976.
8. Sontag S: Illness as a Metaphor. New York NY, Vintage
Press, 1979.
L. 81— NUMBER 5— MAY 1984
385
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, 1NDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, , IN DERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA— either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets—
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING
CAPSULES
Ayerst.
The appearance of
INDERAL LA
capsules is a registered
trademark of
Ayerst Laboratories
ONCE- DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERALLA iii
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg. 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents lor available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, if readjusts lo or below the pretreatment level with chronic
use: Effects on plasma volume appear to be minor and somewhat variable INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients.
In angina pectoris, propranolol generally reduces the oxygen requirement of theheart at
any given level of effort by blocking the catecholamine riduc- d increases m the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol J
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic? |
pressure and systolic election period. The net physiologic effect of beta anrenergtc blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity ii&fy
In dosages greater than required for beta blockadS, INDERAL also exerts a quinidme-like
or anesthetic-like membrane action which affects the cardiac action. potential „Ihe„signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the pial vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital For example' in patients wiftrseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma, 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
388
MAJOR SURGERY. The necessity or desirability of withdrawal of beta-blocking therai
prior to major surgery is controversial. It should be noted, however, that the impaired ability
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthes
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of bet
receptor agonists and its effects can be reversed by administration of such agents, e
dobutamine or isoproterenol. However, such patients may be subject to protracted sevei
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported w
beta blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent the a;
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes))
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be me
difficult to adjust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidis
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptor
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function tes'
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have be
reported in which, after propranolol, the tachycardia was replaced by a severe bradycarc
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 r ,
propranolol
PRECAUTIONS. General . Propranolol should be used with caution in patients with impair:
hepatic or renal function INDERAL is not indicated for the treatment of hypertensij
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patieifi
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal rr|
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart disea:
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as res
pine should be closely observed if INDERAL is administered. The added catecholamu
blocking action may produce an excessive reduction of resting sympathetic nervous acti\
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostc
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals hi
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studie:
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of signific
drug-induced ioxiQty There were no drug-related tumongemc effects at any of the dose
levels. Reproductive studies in animals did not show any impairment of fertility that v
attributable to the drug
Pregnancy Pregnancy Category CT'INDERAL has been shown to be embryotoxic
animaf studies at; doses about 10 times greater than the maximum recommended human do
There are no adequate and weit-controtled studies in pregnant women INDERAL sho
be used during pregnancy only if the potential benefit justifies the potential risk to the fei
Nursing Mothers INDERAL is excreted in human milk. Caution should be exercised wlj
INDERAL i^ac^MsteredJo a nursing woman
Pediatric Use: Safely and effective- est in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and h
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive heart failure; intensification of AV block; hy
tension; paresthesia of hands; thrombocytopenic purpura, arterial insufficiency, usually of
f^ynaudtype. Jm
Central Nervous System ligtitfteadedness; mental depression manifested by msom
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; vi:
disturbances, hallucinations; an acute reversible syndrome characterized by dlsorientatior:
time and place, short-term memory loss, emotional lability, slightly clouded sensorium. .1
decreased performance on neuropsychometrics.
Gastrointestmal. nausea, vomiting, epigastric distress, abdominal cramping, diarrtj
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with act|
and sore throat, laryngospasm and respiratory distress
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopr
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has b
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male in
tence, and Peyronie’s disease have been reported rarely. Oculomucocutaneous react
involving the skin, serous membranes and con|unctivae reported for a beta blocker (pracl
have not been associated with propranolol.
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride
sustained-release capsule for administration once daily If patients are switched from INDE
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapr
effect Is maintained. INDERAL LA should not be considered a simple mg for mg substitul
INDERAL. INDERAL LA has different kinetics and produces lower blood levels. Retitration
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inte
HYPERTENSION — Dosage must be individualized. The usual initial dosage is 8C
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage ma
increased to 120 mg once daily or higher until adequate blood-pressure control is achie
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage o
mg may be required. The time needed for full hypertensive response to a given dosa<
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERA
once daily, dosage should be gradually increased at three to seven day intervals until optn
response is obtained. Although individual patients may respond at any dosage leveli
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value1
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a fewwT
(see WARNINGS). j
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERA™
once daily. The usual effective dose range is 160-240 mg once daily. The dosage mejs
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response ja
obtained within four to six weeks after reaching the maximum dose, INDERAL LA thr V
should be discontinued It may be advisable to withdraw the drug gradually over a peri
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group ai
limited to permit adequate directions for use
♦The appearance of INDERAL LA capsules is a registered trademark of Ayerst LaboralJ
8833 4
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSi
Medical History:
Alabama Granny Midwife*
Linda Holmes, m.pjy., Newark**
Segregation , racism , agrarian economics, and isolation forced
the mcyority of Alabama's rural black women to utilize the
services of a granny midwife in past days . Current practitioners
are incorporating some techniques identical to granny midwife
management approaches during labor and birth .
The history of Alabama’s Afro-
American midwifery practices
must be viewed within the pa-
ameters ot the black experience in the rural South,
vs recently as 1950, segregation, racism, agrarian eco-
lomics, and rural isolation forced the majority of Ala-
bama's childbearing black women to rely on the self-
telp mechanisms of folk practitioners. Hence, the long-
erm isolation of rural blacks from many aspects of
/estem medicine’s influences and controls created an
nvironment ripe for the survival of the “granny mid-
afe." In direct contrast, inhospital physician-managed
hildbirth was the well-established norm for white Ala-
ama women.
It is not surprising that so little that is positive ever
as been written about the granny midwife; histori-
ally, granny midwives in America’s southeastern
fates primarily have been older, empirically trained,
'W-income black women who were tolerated by phy-
icians as necessary evils.1 Now, when granny mid-
wifery practices have been eradicated or soon will die,
nly rare self-descriptions of granny midwifery work
dst.
I went to Alabama in 1981 for seven months to re-
rrd interviews with the state’s last generation of gran-
y midwives. Alabama discontinued the issuance of lay
?rmits for the practice of midwifery in 1976, yet I was
de to obtain a 1977 Midwife Roster compiled by the
fate Health Department containing the names of over
150 lay midwives. By 1981. however, the majority of
these midwives had retired or had been forced out of
business by local health department officials; others
had died. I recorded interviews with 7 individuals who
never had practiced as midwives, but were familiar
with folk practices and beliefs surrounding childbirth.
These persons were valuable informants in confirming
midwifery roles.
The interviews revealed that while the long-tenn
survival of midwifery practices directly was related to
prevailing socioeconomic circumstances, midwifery
work did enrich the life experiences of many southern
black women.
This paper will discuss three aspects of midwifery
work which have affected positively southern Afro-
American communities: midwifery practices have sup-
ported African-based traditions; midwifery has con-
tributed to the health of mothers and babies; and mid-
wifery practices have increased decision-making op-
portunities for black women.
TRADITIONS
Prior to the demise of granny midwifery practices,
*Read before the Medical History Society of New Jersey.
**Ms. Holmes is an Assistant Professor, UMDNJ-Schoo! of
Health-Related Professions. Correspondence may be ad-
dressed to Ms. Holmes, UMDNJ-School of Health Related Pro-
fessions, 100 Bergen Street, Newark, NJ 07103.
)L. 81— NUMBER 5— MAY 1984
389
midwives acted as significant tradition bearers in their
everyday work. Midwifery apprenticeships, in particu-
lar, provided fonnalized mechanisms for passing on
various cultural expressions and knowledge. In the
interviews, many women recalled the specifics of how
they maintained a culturally appropriate rubric for the
labor, delivery, and postpartum process. Some prac-
tices that reflected African traditions included officiat-
ing in rituals such as the disposal of the afterbirth and
presiding at taking up ceremonies — a prescribed ritual
for the reintegration of the mother into her everyday
role following childbirth. The midwives also described
practices similar to African rituals which dictated that
during the postpartum seclusion period, no fire may
be removed from the house and that no house may be
swept.2 Several Alabama midwives spoke of similar
taboos against sweeping under the bed and the re-
moval of ashes from the fireplace.
The following is one mother’s description of the mid-
wifery role in prescribing behavior to be followed after
childbirth:
Well, when the midwife came back and she took
me up and I remember her giving me a dose of
medicine and it was some castor oil to get all the
filth and stuff out of you, so they told me. And then
you had to walk all the way around the house and
come back. It would be up in the day [late in the
day]. If it was in the wintertime, they would make
sure it would be a nice warm day. The coldest time
I had a baby was in March. The midwife would not
let me go outside on that day. She waited till she
found a better day. She came and she got me up,
but she made sure I was back in the bed before
she left .... It would be a month before they threw
the ashes away. If you smoked a cigarette in there,
you couldn’t take it out of there. You couldn’t take
no fire out of the fireplace where they burned the
afterbirth.
Other Alabama practices that paralleled traditional
beliefs included divine calls to practice, belief in the
power of prayer throughout the birthing process, and
reliance on divine guidance in crisis situations. In gen-
eral, the granny women strongly resisted creating
dichotomies between the secular and the religious;
their midwifery work was reflective of this view. While
many midwives requested fees for service— many re-
called charging $5.00 per birth when they began their
practices — midwives often provided care as a God-
given duty without expecting cash payments.
MATERNAL AND CHILD HEALTH
In viewing midwifery work, the most critical aspect
of her practice was in her ability to assist in the birth
of a healthy baby while safekeeping the health of the
mother. Today, the total dominance of medicine in the
baby delivery business obscures the fact that healthy
spontaneous birth is the norm in the overwhelming
majority of childbirth eases with minimal or no tech-
nological intervention required. Since the 1960s, when
consumers began to demand more decision-making
power in the birthing place, greater attention has been
given to the view of childbirth as a basically natural
and normal family-centered event. Ironically, as granny
midwifery practices die, modem health care pro-
fessionals and consumers who accept this childbirth
perspective rapidly are incorporating various tech-
niques and management to labor and birth which are
identical with the age-old granny practices; the efficacy
of such practices now is being confirmed through vari
ous research efforts. There is increasing scientific
evidence, for example, that it is advantageous to keep
mothers ambulant during labor and that encouraging
other than flat-on-the-back, feet-in-stirrups, delivery
table birthing position is beneficial. In the interviews,
the granny midwives frequently talked about keeping
mothers stirring “as long as they could drag" and ofter
defied health department ultimatums demanding tha
mothers give birth lying in bed.3 The use of massage,
with various oils during labor and birth, often referrec
to by the granny midwives, also is popular among mod
em midwives. Even the midwives’ everyday pharma
copoeia including teas, herbs, and household remedies
such as castor oil are regaining popularity for theiij
effectiveness during labor and birth.4 There were ex
treme differences among the midwives interviewed re
garding their admitted familiarity and use of natural
herbs and home remedies. Since the 1890s, when the
issuance of midwifery permits began in Alabama
health department officials adamantly have opposec
the use of any herbs or medications by midwives. Yet
all the midwives interviewed expressed familiarity witl
the use of castor oil as well as black pepper tea anc
dirt dauber’s tea as stimulants for labor even if sue!
teas never were used by them in their own practices
Granny women strongly
resisted creating
dichotomies between the
secular and the religious;
their midwifery work was
reflective of this view.
It must be noted that this research project did no
formally include collecting midwifery statistics. In tb
course of midwifery interviews, however, several of th
more active midwives who reportedly attended mor
than 500 births, recalled 5 or less stillbirths and on
or no maternal deaths. Due to the frequent lack c
formal medical backup and the inclusion of high-risi
patients in midwifery caseloads, many granny mic
wives functioned well beyond the accepted scope c
both the modem lay and nurse midwife; yet, many c
these women reported outstanding maternal and ir
fant mortality/morbidity records.
DECISION MAKING
The supervision of midwifery work by local healtf
departments was said to have ranged from extreme!,
laissez-faire attitudes to close working relationship
with midwives. As long as other health care optiorv
were inaccessible to blacks and as long as women cor
tinued to value birthing customs, many midwive
could exercise a high degree of decision-making re
sponsibility in the privacy of the home setting. Exam
pies of independent decisions which had to be mad
in the management of labor and birth included: whei
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
390
nd to what degree the mother’s activity should be
'stricted during labor; whether to administer any
erbs, teas, or other medications; and whether to en-
nirage alternative birthing positions. If unexpected
nergencies such as a retained afterbirth or multiple
irth presented themselves, immediate decisions were
■quired regarding the feasibility of seeking emergency
edical care. In many instances, midwives had to de-
de whether it made more sense to test their technical
ipabilities or to begin the often complicated process
seeking transportation and finding a hospital where
physician would be willing to provide care to an
digent black woman. Besides making management
•cisions, the midwife often literally took charge of the
)usehold matters as well. She frequently decided who
buld be permitted in the birthing area and she ex-
acted family members to act as supporting personnel
id to cariy out whatever orders the situation de-
:anded.
The other significant aspect of control that midwives
ad in their work was in the selection and training of
; 'prentices. By tradition, midwives acquired their
< ills through observation sessions and training with
rnior midwives, therefore, the senior midwives were
; le to maintain powerful positions in determining
tio entered midwifery ranks. Even when health de-
{ rtment officials actively were recruiting younger
i dwives, senior midwives reportedly denied certain
i:ruits observational experience if these women failed
t meet their standards of eligibility for midwifery
wk. Having good nerves, demonstrating spiritual
cmmitment, actively attending births in the com-
rmity over an extended period of time, exhibiting
nral behavior which was in keeping with senior mid-
vves’ own personal values, and having a midwifery
finily lineage were among the criteria most frequently
ced by senior midwives in assessing potential for
r. dwifery success.
CONCLUSION
As the entire world rapidly moves toward a western
medical approach in the management of childbirth,
opportunities to consider the human value of tra-
ditional midwifery increasingly will become rare. While
the dominant society may have failed to recognize the
significance of the granny midwife, she has been
valued by many childbearing women as an available
source of wisdom and experience. Internationally, the
World Health Organization recently has recognized the
absolute necessity of maintaining the practices of tra-
ditional birth attendants. The concerns of the World
Health Organization, in fact, are similar to those of
some of the interviewed midwives who argued that the
needs of childbearing women simply cannot be met by
the existing pool of physicians. In fact, one midwife
commented, “As long as God is on his throne and God
is yet in Alabama, there will be midwives to provide for
the poor.” Now, however, with less than 1 percent of
all births in Alabama being attended by the grannies,
the midwives for the most part, have accepted their
fates. The acceptance of the death of these age-old
practices, however, in no way diminishes the loss;
these traditions provided indigenous women with ap-
propriate paradigms for the culturally sensitive man-
agement of childbirth for generations.
REFERENCES
1. Alabama's midwifery problem. Med Assoc Alabama
3:148, 1933.
2. Mbiti JS: African Religions and Philosophy. New York,
NY, 1970, 142-157.
3. Dunn PM: Obstetric delivery today. Lancet 1976.
4. Davis L: Use of castor oil for inducing labor in term
patients with premature rupture of membranes. Panel,
American College of Nurse-Midwives Annual Convention,
1983.
- 81— NUMBER 5— MAY 1984
391
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
392
Case Report: Extra-anatomic
Bypasses in Aortoenteric Fistulas
C.H. Antinori, m.d., E.H. Kain, m.d., J.A. Kuchler, m.d., V.J. Manuele, m.d.,
L. Pierucci, jr., m.d., D.T. Villanueva, m.d., camden*
This paper describes the management of two patients with
unusual aortoenteric fistulas. Both patients were managed
successfully by excising the contaminated areas and using extra-
anatomic bypass techniques for limb preservation followed by
protracted parenteral antibiotic therapy.
Aortoduodenal fistula after aortic
aneurysm resection, occurs in
0.5 to 1 percent of cases.1 Spon-
taneous aortoduodenal fistula a rare complication of
abdominal aortic aneurysm, almost always is fatal and,
even if the patient survives to undergo aortic resection
and grafting, mortality is in the range of 50 percent.
Ileocecal fistula is an unusual complication of
aortoiliae or aortofemoral grafting. Aortoenteric fis-
tulas can be treated by extra- anatomical bypass graft-
ing in an attempt to avoid placing a prosthesis in an
area that is contaminated by bowel contents.
We report our experience with two patients with
vascular-enteric fistulas who successfully were treated
by extra-anatomic bypass grafting. The first patient
developed an ileocecal fistula after an aneurysm resec-
tion and the second patient developed a spontaneous
aortoduodenal fistula.
CASE REPORT 1
j
A 78-year-old male had an abdominal aortic
aneuiysm resected and replaced with a Dacron™
aortoiliae prosthesis at another institution in 1979. He
was admitted to Cooper Medical Center in February
1981, with gastrointestinal bleeding. He initially was
hemodynamically stable but during a barium enema
suddenly developed exsanguinating gastrointestinal
hemorrhage and became hypotensive. The patient was
taken immediately to the operating room. At surgery.
a fistula from the midportion of the right limb of the
prosthesis to the cecum was found. The right iliac limb
was removed back to the bifurcation and the end over-
sewn. The native right iliac artery stump was over-
sewn. The opening in the cecum was closed. The ab-
dominal incision was closed and the patient was taken
to the intensive care unit for monitoring and observa-
tion of the status of the leg. The leg immediately began
to look ischemic; the patient was taken back to the
operating room and a femorofemoral bypass graft was
performed using a Dacron™ prosthesis (Figures 1 and
2). Postoperatively, he did well. Cultures taken at the
operation grew Enterobacter aerogenes. He was placed
on a one-month course of antibiotics and made an
uneventful recovery. On a recent admission to the hos-
pital for a cardiac arrhythmia, he had an excellent
pulse in the graft and no signs of infection. He com-
plained of claudication in the leg after walking three
blocks.
CASE REPORT 2
A 73-year-old female was admitted to Cooper Medical
Center in February 1982. She gave a history of obstipa-
tion for a week. The patient was a nonsmoker who had
no significant medical or surgical illness in the past.
*From the Department of Surgery, Cooper Hospital/
University Medical Center, Camden. Correspondence may be
addressed to Dr. Antinori, 455 Route 70 West, Cherry Hill, NJ
08002.
/OL. 81— NUMBER 5— MAY 1984
393
Figure 1 — From case report 1, an ileocecal fistula. Illustration
by James DellaRusso, M.D.
Abdominal examination was remarkable in that no
masses were felt in her abdomen, but the examiner felt
a fecal impaction in her rectum and thought this was
the cause of her problems. Her stool was negative for
occult blood but the hemogram revealed: Hgb, 10; Hct,
33; MCV, 91; MCH, 30; and MCHC, 32.7. She had a
white count of 10,000 and a normal differential. Her
sedimentation rate was elevated and her SMA 12
showed an LDH of 411, SGOT of 256, and alkaline
phosphatase of 329. Bilirubin was 1.1 and total protein
was 5.9. Her BUN, creatinine, and electrolytes were
normal. The patient persistently complained of cramp-
ing abdominal pain and therefore an extensive
diagnostic evaluation was needed.
Chest and abdominal x-rays and liver-spleen scan
were normal. Ultrasound showed a normal gallbladder
and pancreas. Barium enema revealed scattered
diverticuli, but no other lesions. While the patient was
being evaluated, she suddenly developed rapid gastro-
intestinal bleeding with the passage of large amounts
of maroon-colored stool per rectum. Her blood pressure
remained 100/70, but her pulse accelerated to 120.
Immediate endoscopy revealed a gastric ulcer and what
was interpreted to be bleeding from duodenitis. The
patient continued to bleed rapidly in spite of intensive
medical therapy, and she was taken to the operating
room. Although the preoperative diagnosis was upper
gastrointestinal bleeding due to peptic ulcer disease,
the surgeon found an aortoduodenal fistula with an
•Jw*
Figure 2 — From case report 1, resection of fistula and re
construction with femorofemoral bypass. Illustration b\
James DellaRusso, M.D.
abdominal aortic aneurysm that measured 4 cm in
diameter. The distal aorta and iliacs were oversewn; a
lateral closure of the duodenum and a gastro-
enterostomy to bypass this area were performed. The
abdominal incision then was closed and a right axil-
lobifemoral artery bypass graft was performed to the
common femoral arteries using a 10 mm Dacron™
prosthesis (Figures 3 and 4). Postoperatively, she re
mained hemodynamically stable and recovered ex-
tremely well. Cultures taken during surgery grew an
alpha hemolytic Streptococcus. A one-month course ol
parenteral antibiotic therapy was administered. At the
time of discharge, the patient had good pulses in the
graft and the extremities felt warm. She has remained
well.
DISCUSSION
Aortoenteric fistulas of any etiology are extremel}
uncommon, but most develop after prosthetic replace-
ment of the abdominal aorta Spontaneous aortodu-
odenal fistula is an extremely unusual complication of
an abdominal aortic aneurysm. Reckless et al. reviewed
the literature up to 1972 and found only 128 cases
with 15 patients treated surgically and 5 survivors.2
Lewis et al. reviewed the literature in 1979 and found
64 cases reported since 1957. 3 Only 28 patients were
treated surgically and 14 patients survived. Our pa-
tients demonstrated the typical pattern of a “herald
bleed" with a “period of grace” prior to the ex-
394
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Figure 3 — From case report 2, an aortoduodenal fistula. Il-
lustration by James DellaRusso, M.D.
figure 4 — From case report 2, resection of aneuiysm and
,'istula reconstruction with axillobifemoral bypass. Illustra-
ion by James DellaRusso, M.D.
•anguinating hemorrhage resulting in cardio-
vascular collapse. The physical examination should re-
peal the pulsatile abdominal mass, but in our second
ase, an obese woman with a small aneurysm, the
meurysm was not appreciated by palpation. Ab-
lominal ultrasonography or CT scan focusing on the
torta probably would have demonstrated this
lineurysm.
The usual treatment of choice for aortoenterie fis-
tulas is removal of the prosthesis, if possible, and
closure of the distal aorta lateral repair of the bowel;
and extra-anatomic vascular bypass if neeessaiy. We
feel that extra-anatomic bypass is the treatment of
choice because of our experience with several patients
in whom residual prosthetic material in the con-
taminated field resulted in late recurrence of infection.
This complication proved virtually impossible to treat.
Others report similar experiences.4 6 In our first ease,
the right iliac limb of the prosthesis was removed all
the way up to the bifurcation. This provided a margin
of several centimeters away from the fistula. The native
distal iliac artery then was oversewn. Thus, there was
no prosthetic material left in the contaminated area.
In our second case, no prosthetic material was left in
the abdomen.
The patency rate for extra-anatomic bypasses, in
many series, is similar to that of aortoiliac bypasses.
Blaisdell et al. recorded a two-year patency rate of 80
percent with femorofemoral bypasses and 50 percent
for axillofemoral bypasses.6 Johnson’s group reported
even better results with axillobifemoral bypass grafts;
they had a 76 percent five-year patency rate which was
similar to their results with aortoiliac bypass, though
the extra-anatomic bypasses required more frequent
“remedial” surgery to keep them patent.7 We also have
been very satisfied with our extra-anatomic bypasses
done in other settings.
SUMMARY
Two unusual cases of vascular-enteric fistulas are
presented. Both cases exhibited the typical pattern of
a small “herald bleed” followed by a grace period of
several days before subsequent exsanguinating
hemorrhage. Both patients were treated successfully
utilizing the principles of excision of contaminated
prosthetic material, extra-anatomic bypass, and long-
term antibiotic therapy.
REFERENCES
1. Easteott HHG: An appraisal of the use and functions of
vascular grafts in England, in Sawyer PN, Kaplitt MJ (eds):
Vascular Grafts. New York, NY, Appleton-Centuiy-Crofts,
1978.
2. Reckless JPD, McColl I, Taylor GW: Aortoenterie fistulas:
An uncommon complication of abdominal aortic aneuiysms.
Br J Surg 59:458-460, 1972.
3. Lewis RT, Allan CM: Spontaneous aortoduodenal fistula:
Successful treatment by extra-anatomic vascular bypass. Can
J Surg 22:234-236, 1979.
4. Evans DM, Webster JHH: Spontaneous aortoduodenal
fistula Br J Surg 59:368-372, 1972.
5. Elliott JP Jr, Smith RF, Szilagyi DE: Aortoenterie and
paraprosthetie-enteric fistulas: Problems of diagnosis and
management. Arch Surg 108:479, 1974.
6. Holcroft JW, Conti S, Blaisdell FW: Extra-anatomic
bypass grafts. Surg Clin North Am 59:649-658, 1979.
7. Johnson WC, Logerfo FW, Vollman RW, Corson JD,
O'Hara ET, Mannick JA Nabseth DC: Is axillo-bilateral
femoral graft an effective substitute for aortic-bilateral
iliac/femoral graft? Ann Surg 186:123-129, 1977.
7OL. 81— NUMBER 5— MAY 1984
395
As in Blue Cross of New Jersey. The
single source for computerization.
□ Because Medical Management
Services from Blue Cross now offers
a unique automated office system.
□ Only Blue Cross offers this unique
system, because only Blue Cross has
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You receive a stand-alone system
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The software and system
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This modular system provides a com-
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Your people receive full and com-
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What the system does
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Some of what you
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> An easy-to-use system.
> Instant access to patient account
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Take a minute to check
this list!
□ Your volume is at least 80 patients
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□ Your daily cash control and records
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□ Your receivables are greater than
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management information about
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□ Your "most current” financial
statement for the practice is
already out of date.
If you have checked off any of the above, you
are a candidate for Medical Management Services.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
396
uterization?
Mu
■ Production of patients' statements
on daily, weekly or monthly basis
— whichever billing cycle is best for
your practice.
Automatic production of standard
insurance (AMA) claim forms.
A daily charge and collection sum-
mary which recaps all daily patient
activity.
An aged accounts receivable trial
balance which can be printed on
demand.
Practice productivity reports broken
down by procedures and payment
classifications (insurance, self-pay, etc.)
> Monthly management reports.
> Medicare payment distribution
(20% of co-pay automatically cal-
culated if assignment is accepted).
> Single-date entry for all financial
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> A recall system which prints lists,
statistics and "labels."
> Customized reports for special
requirements.
> Automatic retention of claims
information for rebilling purposes.
> Improvement in cash flow and
office efficiency.
Free Office Analysis
Included in the services provided is a
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Management Services representative
analyzes pertinent data on your cur-
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PL. 81— NUMBER 5— MAY 1984
397
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Case Report: Pancreatic Pseudocyst
Associated with Valproic Acid Therapy
Arnold m. Baskies, m.d., willingboro*
Our patient was treated with anticonvulsant medications
including valproic acid. The patient developed gastric outlet
obstruction and was diagnosed as having a pancreatic
pseudocyst probably secondary to pancreatitis from valproic
acid therapy. This is the first report of such a complication
possibly due to this medication.
Previously reported side effects of
valproic acid (Depakene*) in-
clude hematological ab-
lormalities, hepatotoxicity, and pancreatitis.1 2 This
>aper presents a previously unreported association of
iancreatic pseudocyst with valproic acid therapy.
)ASE REPORT
Our patient is a retarded, 19-year-old white male
/ho was hospitalized for evaluation of persistent
omiting, mild hematemesis, weight loss, and ab-
lominal tenderness.
He was the product of a full-term, uncomplicated
regnancy, and developed normally until 18 months of
ge when he developed Hemophilus influenzae men-
ngitis followed by coma for two weeks. Thereafter, he
eveloped psychomotor and minor motor seizures,
pastic tetraparesis, and severe mental retardation.
In 1975, at age 14 years, he had generalized tonic-
ionic seizures. In 1976, he had 8 tonic-clonic seizures;
p 1977, he had 13 tonic-clonic seizures and 254
linor motor seizures. Valproic acid (15 mg/kg) was
irescribed in October 1978, and the dose was later
icreased to 23 mg/kg, resulting in a dramatic reduc-
ion in the seizure frequency. In March 1979, he was
valuated at another medical center for aspiration
neumonia, decreased oral intake, vomiting, and a five-
ound weight loss. A Stamm gastrostomy was per-
3rmed. He did well until January 1980, when vomiting
'OL. 81— NUMBER 5— MAY 1984
recurred. An upper gastrointestinal series and barium
enema were normal. He was found to have guaiac
positive vomitus and tarry stools. His serum amylase
was 91 (normal: 50 to 200). In February 1980, because
of persistent vomiting, the patient was admitted for
evaluation. His medications on admission consisted of
valproic acid 250 mg t.i.d., phenobarbital 30 mg b.i.d.,
and phenytoin 250 mg/day. Examination revealed
epigastric fullness. A repeat upper gastrointestinal
series revealed a markedly effaced stomach displaced
anteriorly; the duodenal loop was displaced to the
right. A sonogram showed a large pancreatic
pseudocyst with a normal gallbladder. Laboratory
studies included serum calcium level of 8.9 mg/dl, nor-
mal liver function tests, and valproic acid levels rang-
ing between 27 and 5.3 mg/dl (therapeutic 5 to 10
mg/dl).
At surgery, a large retrogastric pseudoeyst, with a
thick, mature wall, densely adherent to the posterior
gastric wall was found. The pseudoeyst contained 800
ml of murky, greyish fluid and necrotic material. Palpa-
tion of the gallbladder revealed no stones. A
cystogastrostomy was performed and the patient re-
covered uneventfully. He has been asymptomatic.
*From Zurbrugg Memorial Hospital where Dr. Baskies is af-
filiated with the Department of Surgery. Correspondence may
be addressed to Dr. Baskies, Zurbrugg Memorial Hospital,
Raneocas Valley Division, Willingboro, NJ 08046.
399
DISCUSSION
Valproic acid is an oral anticonvulsant; structurally,
it is a short-chain fatty acid which is unrelated
chemically to other anticonvulsant agents. It is used
adjunctively for simple or complex absence seizures
and for patients with multiple seizure types which
include absence spells.
When compared to other anticonvulsants, adverse
reactions are few. Among the more common side ef-
fects are nausea vomiting, colic, and diarrhea anorex-
ia and increased appetite may occur. Alopecia rashes,
headaches, insomnia, sedation, excitation, and
behavorial changes have been observed. More serious
reactions include hepatotoxicity, thrombocytopenia
inhibition of platelet aggregation, and decreases in
fibrinogen levels.
A literature review reveals reports of three patients
with pancreatitis associated with valproic acid ther-
apy.12 To the best of our knowledge, our case is the first
report of a possible association between valproic acid
therapy and pancreatic pseudocyst formation. Absence
of other causes for pseudocyst formation in this pa-
tient makes it likely that valproic acid was responsible
for the development of the pseudocyst.
The three previously described cases of pancreatitis
and our case of a pancreatic pseudocyst, which
presumably was a sequel to undiagnosed pancreatitis,
emphasize the need for monitoring pancreatic func-
tion in patients receiving valproic acid. Such monitor-
ing would appear to be indicated especially where
gastrointestinal signs and symptoms are present.
When a pseudocyst is present, the serum amylase may
be normal,6 as was the case in our patient, but a 24-
hour amylase clearance determination and an ab-
dominal ultrasound may help establish the diagno-
sis.3'5
Physicians who prescribe valproic acid should be
aware of possible pancreatic damage as a result of this
therapy and should confirm and treat this problerr
promptly.
REFERENCES
1 . Batalden P, VanDyne BJ, Lloyd J: Pancreatitis associatec
with valproic acid therapy. Pediatrics 64: 520-522, 1979.
2. Canfield PR Bagnessl P, Camfield CS, Tibbies JA Pan
creatitis due to valproic acid. Lancet 1:1198-1199, 1979.
3. Cooney DR Grosfeld JL: Operative management of pan
creatic pseudocysts in infants and children: A review of 71
cases. Ann Surg 182:590-596, 1975.
4. Rose JS, Becher JH, Staiano SJ, Campos E: Proceedings
B-mode sonographic evaluation of abdominal masses in th<
pediatric patient. Am J Roentgenol Radium Ther Nucl Mec
120:691, 1974.
5. Owens BJ, Hamit HF: Pancreatic abscess and pseudocyst
Arch Surg 112:42-45, 1977.
6. Wood RAB, Moossa AR Blackstone MO, Bowie J, Collin:
P, Lu CT: Comparative value of four methods of investigatini
the pancreas. Surgery 80:518-522, 1976.
400
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Ainslie, William H,M.D.
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Alcasid, B. I., M.D
Alexander, Raymond T, M D.
Allgair, William A., M.D.
Alvarez, Reinaldo G., M.D.
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Amendo, M.T., M.D.
Amorosa, Judith, M.D
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Aruna, Pasalai N., M.D
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Athanas, Efthimios, M.D.
Babar, Abdul H., M.D
Babar, Mumtaz J., M.D.
Baiser, Dennis M., M.D
Bakhos, Abdel M„M.D.
Balinski.Thaddeus A., M.D.
Ball, Richard M., M.D.
Bancila, Alexandru, M.D
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Baril, Carlo T., M.D
Barofsky, Norman, M.D
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Beauchamp, David T., M.D
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Behman, Mankarios S., M.D
Belafsky, Henry A., M.D.
Belkoff, M. Michael, D O
Berkow, Bori, M.D
Berkow, Lester H., M.D.
Blackman, Edward L., M.D
Blondo, Dennis L., M.D.
Bloom, Herbert, M.D.
Blum, Richard H., M.D.
Bogart, Waiter B., M.D.
Boodin, Bernard B., M.D.
Boogdanian, Victor H., M.D
Borow, Maxwell, M.D.
Borrus, Joseph C., M.D
Borsky, Martin, M.D
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Boylan, Joseph I., Jr., M.D.
Brady, Edward A., M.D
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Buck, Warren G., M.D.
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Bunin, Sara Ann, M.D
Burks, William P., M.D.
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Caldora, John B., M.D.
Campos, Humberto, M.D.
Cannamela, Vincent J., M.D.
Capitly, Domiciano V., M.D.
Capotosta, Thomas J., M.D
Carabelli, A. Albert, M.D.
Carabuena, Ramon, M.D.
Cardinale, Robert, M D.
Carlson, Lennart A., M.D.
Carney, Alexander S., M.D.
Carroll, Bruce J., M.D
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Chandler, James J., M.D.
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Chen, Michael T., M.D.
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Chinitz, Jack, M.D.
Cho, Chang C., M.D
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Choi, Soon C., M.D,
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Chuirco, Anthony A., M.D.
Chung, Uei K., M.D
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Diemer, Louis M., Ill, M.D.
Dietzel, Herbert A., M.D
Donatelli, Anthony, A., M.D.
Dooley, Charles E., Jr., M.D
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Dy, Ceferino T., M.D.
Eibschutz, Ghitta, M.D
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Frank, Steven A., M.D
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402
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
r afael, M.D
Ibert S., M.D.
Iph J., M.D
: dney B., M D
U J.A., III, M.D
kanna W., M.D
Fncis B., M.D.
» Harris C., M.D.
i K., M.D
I iel R., M.D
II ed S., M.D.
t, M.D.
l^ne J., M.D.
H1 M.D
>., M.D.
Ophen M., M.D
is, James N., M.D.
(Theodore, M.D
Dominick T., M.D.
Ii nan L„ M.D.
pncheria, M.D
Iklardino, M.D.
Michael, M.D.
r
ement A., M.D.
lohn S., Jr., M D
fn, Zenaida A., M.D.
, Pavani, M.D
Donna D., M.D.
E silS., M.D.
Man, M., M.D.
I larc I., M.D.
II lid M., M.D.
George M., M.D
rderic J., M.D.
• Hip J., D O
> anley S., M.D
ii Ira E., M.D
ii, Jon, M D
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pone, Angelo, M D
Ebert S., D O
1 gin V., M.D
MS., DO.
i homas 0., M.D.
1 , Donald F., M.D.
Frederick J., M.D.
n Daniel P., Jr., M.D
s rancis D., M.D
r, John E„ IV, M.D
1 J., M.D.
i raham, M D
, atthew, M.D.
Iiurice S., M.D.
, igelo J., M.D.
<ard H„ M.D.
Mry J.,M.D
MS, M.D.
fflRichard, D O
i, atu.M.D.
tjM., M.D
Oaniel N., M.D.
>3, Rufino D„ M.D.
seph L., Jr., M.D.
t ), Michael A., M.D.
, ager V., M.D
dul W., M.D
\liam F., M.D
J I, M.D.
HMarayanan, M.D
Needell, Gary S., M.D.
Neumaier, George J., M.D.
Newman, Richard, M.D.
Nicora, Bernard J., M.D.
Niemiera, Alexander K., M.D.
Nisar, Mohammed M., M.D
Nishitani, Noboru, M.D
Noronha, Joaquim L., M D
Nosher, John L., M.D
Nozick, Jerome H., M D
Null, Robert H., M.D
Obaray, Akbar H., M.D
Ocken, Paul R., M.D.
Oh, Youn K., M.D.
Oliver, Lawrence H., M.D.
O’Neill, Earl A., M D
Ongsiako, Rodolfo G., M.D.
Orenstein, David H., M.D
Osborne, Alan W„ M.D.
Oshin, David R., M.D.
Ostrowski, Edward J., M.D
Packer, Stuart H., M.D
Paglia, Ludwig R„ M D
Pallini, Carlo A., M.D
Palmieri, Alphonse P., M.D.
Palmieri, Frederick, Jr., M D
Palsky, Glenn S., M.D
Pancer, Bernard, M.D
Pandya, H.D., M D.
Panzer, Edward I., M.D
Pappas, Constantine, M.D
Paraskevas, Angelos L., M.D
Parikh, Sheela N., M.D.
Parikh, Sudhir M., M.D.
Park, Young Ho, M D
Parker, Martin I., M.D
Passannante, A.J., M.D
Patel, Daksh B.,M D
Patel, Ishvarlal U., M.D
Patel, Natverlal M., M.D
Patel, Sushila B., M.D.
Pecora, John J.,M D
Pellicane, Joanne E., M.D
Perillo, Louis A., M.D
Perkoff, Morton, M.D
Piazza, Gary G., D O
Pica, Vincent B., M.D
Pickens, Robert L., M.D.
Piezas, Mabini, C., M.D.
Pirog, Eugene P., M.D
Pironti, Pascal A., M.D.
Pizzi, Francis J., M.D.
Platt, Marvin, M D
Posta, Alan G., M.D
Potash, Ronald J., M D
Prasad, Rajendra G.,M.D
Prepon, Michael A., M D
Press, Lorin R., M.D
Prodromo, Paul E., M D
Proshan, Neil, M.D.
Puchner, Gerhard, M.D.
Pumo, Jerome, Jr., D O
Puri, Kamal, M D
Rahill, William Joseph, M D
Raja, Malayandi, M.D
Rao, Vatsala V., M.D
Raza, Mohammad A., M.D
Reddy, Chenna G., M D
Reissman, David I., M.D
Rezvan, Masoud, M.D,
Robbins, Joseph A., D O
Roberts, Dudley A., M.D
Roberts, R. Michael, M D
Rogers, John C., M.D.
Rogow, Louis M., M.D
Romano, Frank R„ M.D
Roowala, Shabbir H., M.D
Roque, Celia G., M.D.
Rosen, Alex, M.D.
Rosenbaum, Jeffrey M., M D.
Rosenberg, Stanley E., M.D
Rosenblum, Howard W., M.D
Rosenfeld, David L„ M D
Rosenman, Howard D„ M D
Rosenstein, Martin J., M.D
Rosenthal, Steven, M.D
Rosner, Bruce P., M D.
Rossy, William H., M D
Roth, Arthur L„ M.D
Rothfarb, Steven H., M.D.
Rothfleisch, Sheldon, M D
Rubenstein, Laurence, D O
Rubin, Jack D., M.D
Rubin, Marc R., M.D
Rubin, William, M.D
Ruderman, Armand L„ M.D
Rudnitzky, Elliot M., M D
Rushnak, Michael J., M.D
Russell-Brown, Karl E., M.D.
Sabety, Adrian M., M D
Safdar, Feroz, M.D
Safer, Jan N.,M D
Saini, Balwant S., M D
Sakson, John A.. M.D
Saladino, Joseph R., M.D
Saleem, Mohammed R., M D
Saltstein, Elliott, M.D
Salvati, Carl A., M.D
Sand, Harold A., M.D
Santiago, Alectis R.,MD
Santiago, R. Nito, M.D
Santoro, Anthony F, M D
Santoro, Edgar V., M.D
Santucci, Frank P., M D
Sarkanich, Natalie L., M D
Sarkaria, Jasbir S., M.D
Sarraf, Mohammad A., M D
Sass, D.K., M.D
Sawhney, Om P., M.D.
Sawhney, Veena K., M.D
Scharf, Jeffrey I., M.D.
Schinco, Frank P., M.D.
Schlesinger, Richard S., M D
Schnall, Stanley J., M.D
Schneider, Samuel, M.D
Schnur, Bernard M., M.D
Schoicket, Daniel P„ M.D
Schoss, Maximillian, M.D
Schottenfeld, Mark A., M.D.
Schriever, Henry G., M.D
Schulman, Melvin L., M.D
Schwartz, Louis E., M D
Schwartz, Milton D., M D
Sckalor, Martin, M.D
Scully, John T., M.D
Seed, John C., M D.
Segarra, Michael, M.D
Seitzman, Lawrence A., M.D
Sergeant, John H., M.D
Shadiack, E.C., Jr., D O
Shafi, Mohammad, M.D
Shah, Ramakant J., M D
Shah, Suresh N„ M D
Shah, Syed G., M.D
Shangold, Jack E., M D.
Shapiro, Robert S., M.D
Sharett, Terrence E., M.D
Sharim, Iradj, M.D.
Sharlin, David N., D O
Sharma, Madho K., M D
Sharrett, Richard H.,M D
Sheehy, Martin J., M.D
Sheldon, Ira, D O
Sherwood, Edward S., M.D
Shugar, Ronald A., M D
Sicherman, Harlan J., M.D
Silverman, Leon, M.D
Silverman, Samuel H., M.D
Silverstein, Michael L., M D
Simpson, Alec N., M.D
Sinha, Gopal K., M.D
Sisler, Glenn E., M D
Sklar, Samuel, M.D
Skobel, Barry, M.D.
Skvara, Frederick C., M D
Slobodien, Howard D., M.D
Smith, Charles I., M.D
Smith, J. Michael, M.D
Smith, Sydney F., M.D
Smith, Theresa Ann, M.D.
Snope, Frank C., M D
Solanki, Indukumar M., M D.
Solomon, Robert B,,M.D
Somerstein, Michael L., M.D
Soriano, Bruce V., M D
Soriano, Carlos C., M.D.
Soriano, Myrna L., M.D
Sorvino, A. Ronald, M.D
Speiden, Lois M., M D.
Spierer, Robert, M.D
Spiler, Ira J.,M D
Sprowls, John J., M.D
Stabile, John R„ M D
Stahl, Martin B., M.D
Stahl, Theodore J., M D
Stein, Elliott M„ M.D
Stern, Alan G., M D
Steward, Robert E., M.D.
Subramoni, V., M D
Sullivan, Bessie M., M D
Surowiec, Barbara, M.D
Sweberg, Warren A., M D.
Swee, David E., M D
Sweeney, William A., M D
Tabachnick, John F., M.D
Taboada, Javier G..M.D
Tallia, Alfred F., M.D
Tan, Fiorello I., M.D
Tan, Roland P., M.D
Tena, Leoncio B., M.D
Terry, Bernard, M.D.
Thirugnanam, S., M D
Tiedemann, Richard N., M.D
Tokar, Elliot S., M.D
Tong, Yeow Ching, M.D
Trachtenberg, E.B., M.D
Tuma, Victor B., M.D.
Turkish, Sheldon C., M D
Tyrrell, Eugene J., M.D
Uray, Maria N., M.D
Uray, Tacettin M.,M D
Vafai, Armine, M.D
Valencia, Linda 0., M D
Valencia, Rogelio R., M D
Valenzuela, Albert P., M.D
Van Horn, Paul E., M D
Verdoni, John A., M D
Vine, Sherwood, M.D
Viswanathan, Uma M., M D
Wadle, Rudi 0., D O
Wald, Franklin D., M D
Waleson, Max, M.D
Wang, Ching Jen, M D
Warfield, William S., M D
Warner, Errol, M D
Warren, Bertram, M D
Warren, Stephen, M D
Waskow, Walter H., M D
Weber, Charles M., M D
Weinberger, George I., M D
Weingarten, Michael C., M.D
Weinstein, Rita, M.D
Weisenreider, John, M D
Weiser, Paul J., M D
Weisfogel, Gerard M., M D
Weissman, Kenneth, M D
Weissman, Murray H. M.D
Weitzman, Robert H., M D
Welt, Howard, M D
White, John J„ Jr, M.D
White, Sanford F., M.D
Wiener, Howard E., M.D
Wijaya, K.D. Henry, M.D
Willard, David A., M D
Williams, David M., M D
Williams, Manley C., M D
Williams, Paul T., M D
Willis, Elliott H„ D O
Winant, John G., Jr., M.D
Wininger, Jon G„ M D
Wittenborn, W.F., Jr., M.D
Wolansky, Jacob, M.D
Wong, J.C., M D
Wong, Michael Y..M D
Worth, David A., M.D
Wosnitzer, Morey, M D
Wozniak, Ronald F., M.D
Wu, Hen-Vai, M.D
Yarian, David L., M D
Yatrakis, Nicholas D., M D
Yood, Harold S., M D
Young, Alan, M.D
Yu, Micky U., M.D
Zablocki, Lisa R., M D
Zadeh, Moloud A., M D
Zicherman, Barry, M D
Zimmerman, Stanley R., M D
Zingarini, Mario L., M D
Zoba, Tim C., M D
Zobel, George J., D O
Zubair, Mohammed, M D
Zullo, Joseph C., M D
Zullo, Robert J., M.D
Zutz, Harry M„ M D
Zykorie, David, M D
HealthWays
THE WAY TO BETTER J HEALTH CARE
HealthWays Inc. • Parkway Towers
485 U.S. Route i • Iselin, NJ 08830
800-223-0812.
>L. 81— NUMBER 5— MAY 1984
403
Case Report: Familial Dysalbuminemic
Hyperthyroxinemia— a Variant
Michael H. Goldman, m.d., and Karl Klinges, m.d., englewood*
Elevated T4 levels seen in familial dysalbuminemic
hyperthyroxinemia may mistakenly suggest hyperthyroidism.
An elevated uptake and scan seen in the patient presented
further confused the true euthyroid state.
Familial dysalbuminemic hyper-
thyroxinemia (FDH) recently
was described in patients with
an elevated T4 level and an elevated Free Thyroxine
Index, but showing a clinically euthyroid state.1 6 Con-
firming this normal thyroid status is a normal T3 RIA,
a normal thyroid stimulating hormone (TSH) response
to thyroid releasing hormone (TRH), and a normal
thyroid uptake of iodine. In our case report, a patient
with FDH is described who further confuses the over-
lap in laboratory differentiation of T4 excess states by
having an elevated uptake and scan.
CASE REPORT
Our patient was a 22-year-old white female referred
for consultation due to a high T4 level. She gave no
history of hyperthyroid symptomatology. Her past
medical history was unremarkable and there was no
family history of thyroid disease. She recently was
evaluated for secondary amenorrhea but presently
menstruates every 40 days. Physical examination con-
firmed a euthyroid state and the thyroid was judged
to be normal. No ophthalmopathy was noted. (Table)
A six-hour 1-123 thyroid scan and uptake revealed
a slightly enlarged gland with an elevated uptake 18.6
percent (normal 13 percent).
Because of the patient's clinical euthyroid state, nor-
mal T3 RIA and TRH stimulation test, no therapy was
felt to be indicated.
A brother of the patient who was unable to be eval j
ated had the following laboratory data T3 RIA 16
(normal: 110 to 235 ng/dl), T4 RIA 17.6 (normal: 5
12 mcg/dl), T3 RU 45 (normal: 35 to 45%), Free T4 1
(normal: 1 to 2.3 ng/dl). He reportedly shows no sigr
or symptoms of hyperthyroidism.
DISCUSSION
Hyperthyroxinemia does not always mean hype
thyroidism. Elevated thyroid binding globulin (TBG
peripheral resistance to thyroid hormone, and a r<
cently described condition called familial dy:
albuminemic hyperthyroxinemia (FDH) can increas
T4 levels without causing a clinical thyroid exces
state.1 9 Increased TBG reflects an increased binding (£
T4 to its protein and the T3 Resin Uptake usually
depressed giving a normal Free Thyroxine Index (FTI
In resistant states the FTI is elevated, but the thyroi
stimulating hormone (TSH) inappropriately is ii
creased reflecting an insensitivity to circulatir
thyroid hormone. In FDH, the FTI is increased becauJ
of the abnormal excessive binding of T4 to albumi
which then is measured along with the T4 bound b
TBG and prealbumin. This patient’s albumin bindir
*From Englewood Hospital, where Dr. Goldman is Attendin
Department of Medicine, and Dr. Klinges is Attending, D
partment of Obstetrics-Gynecology. Correspondence may 1 (
addressed to Dr. Goldman, 600 Palisade Avenue, Englewoc
Cliffs, NJ 07632.
N
404
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
TABLE
Laboratory Report
Laboratory Tests
Patient
Normal
T,
19, 17, 23, 23 mcg/dl
5 to 12 mcg/dl
T3. RIA
157 ng/dl
110 to 230 ng/dl
T3 RU
39, 45%
35 to 45%
(Baseline) TSH
4, 2 MlU/ml
<7 MlU/ml
(Post TRH) TSH
18 MlU/ml
12 to 32 MlU/ml
Free T4
2.1 (x2) 2.8, 2.3 ng/dl
1 to 2.3 ng/dl
LH
14 MlU/ml
6 to 30 MlU/ml
FSH
5 MlU/ml
4 to 30 MlU/ml
Prolactin
30, 15 ng/ml
<22 ng/ml
TBG
22 mcg/ml
12 to 28 mcg/ml
Electrophoresis of T4 1-125 Binding*
Laboratory Tests
Patient
Control
TBG
40.7%
60.3%
Albumin
41.2%
7.4%
TBPA (Thyroid-binding Prealbumin)
18.0%
33.0%
* Courtesy of Dr. Ingbar, Thorndike Laboratory, Harvard Medical School.
as nearly six times normal. In contrast to patients
1th hyperthyroidism, persons with FDH have a nor-
mal T3 RIA and a normal TSH response to TRH. In
previously reported FDH cases, patients also had nor-
al thyroid uptake of iodine. One report mentions a
ight thyroid enlargement.9
The patient described here had an increased iodine
Dtake along with a mild thyroid enlargement; no
ason for this elevation is apparent. She took no anti-
ivroid drug, had no antimierosomal or anti-
yroglobulin antibodies, and did not come from an
dine deficient area. She does not have coincidental
'inieal hyperthyroidism. Whether this abnormality of
yroid uptake in conjunction with FDH has any
1 nical importance remains to be determined.
Along with an elevated T4 level, the increased uptake
:!ds another confusing laboratory abnormality noted
occur in patients with FDH. This further may ineor-
Ijctly suggest hyperthyroidism. A normal T3 RIA and
TH stimulation test will help identify this problem.
The familial nature of this disorder strongly is sug-
sted as the brother of the patient showed laboratory
1 ta eompatable with the FDH syndrome: an elevated
, a high-normal T3 RU, but a normal T3 RIA and a
I’rmal free T4. Formal electrophoretic confirmation
ijifortunately was unavailable.
iMMARY
\ patient with familial dysalbuminemic hyper-
|roxinemia is presented. In contrast to the few
yviously reported cases, this patient had an elevated
! ine uptake along with an enlarged thyroid gland. In
addition to an increased T4 level, confusion with a
hyperthyroid state was suggested. A normal T3 RIA and
TRH stimulation test helped differentiate this problem.
REFERENCES
1. Ruiz M, Rajatanavin T, Young RA, et al.: Familial dys-
albuminemie hyperthyroxinemia- A syndrome that can be
confused with thyrotoxicosis. N Engl J Med 306:635-639
1982.
2. Lee WNP, Golden MP, Van Herle AJ, Lippe BM, Kaplan
SA Inherited abnormal thyroid hormone-binding protein
causing selective increase of total serum thyroxine. J Clin
Endocrinol Metab 49:292-299, 1979.
3. Hennemann G, Doeter R Krenning EP, Box G, Otten M,
Visser TJ: Raised total thyroxine and free thyroxine index but
normal free thyroxine. Lancet 1:639-642, 1979.
4. Stockigt JR Topliss DJ, Barlow JW, White EL, Hurley
DM, Taft P: Familial euthyroid thyroxine excess: An ap-
propriate response to abnormal thyroxine binding associated
with albumin. J Clin Endocrinol Metab 53:353-359, 1981.
5. Borst GC, Premachandra BN, Osbume RC, Burman KD,
Johnsonbaugh RE: Euthyroid, familial hyperthyroxinemia
due to an abnormal thyroid-hormone-binding protein. 63rd
Annual Meeting, Endocrine Society, Cincinnati, OH, June
17-19, 1981.
6. Moses AC, Lawlor J, Haddow J, Jackson IMD: Familial
euthyroid hyperthyroxinemia resulting from increased
thyroxine binding to thyroxine-binding prealbumin. N Enql
J Med 306:966-969, 1982.
7. Refetoff S: Thyroid function tests, in: DeGroot LJ (ed),
Endocrinology. New York, NY, Grune & Stratton, 1979.
8. Refetoff S, DeWind LT, DeGroot LJ: Familial syndrome
combining deaf-mutism, stippled epiphysis, goiter, and ab-
normally high PBI: Possible target organ refractories to
thyroid hormone. J Clin Endocrinol Metab 2 1 :279-294, 1 967.
9. Weintraub BD, Gershengorn MC, Kourides LA et al.: In-
appropriate secretion of thyroid-stimulating hormone. Ann
Intern Med 95:339-351, 1981.
T. 81— NUMBER 5— MAY 1984
405
COMMENTARY: DRG— NEW JERSEY
and the Federal System*
Bernard A. Rineberg, m.d., new Brunswick**
Major differences between New Jersey and federal DRG exist , yet
no conclusion can be surmised because of incomplete data.
Nonetheless , the federal government has adopted and modified
the plan. These modifications could have a major impact on the
New Jersey system.
On October 1, 1983, two signifi-
cant events occurred simul-
taneously. Most prominently,
the American Telephone and Telegraph Company
underwent divestiture. Secondly, and possibly just as
importantly, prospective reimbursement to hospitals
based upon case mix or more commonly known as
Diagnosis Related Groups (DRGs) became the method
of payment for Medicare recipients to hospitals in this
country. These events are not entirely unrelated.
In the case of AT&T, a giant 19th-century monolith
was broken up to create competition between the dif-
ferent factions. In the case of DRGs, hospitals will be-
come more competitive to maintain their existing mar-
ket share. In both industries, the ability to control
costs and increase productivity while simultaneously
decreasing excessive spending will be crucial to suc-
cess. However, in either case, there is no assurance
that the programs can or will achieve the goals which
their proponents have predicted.
The DRG experience became operational in 1979 for
more than 20 hospitals throughout New Jersey. Soon
after, all hospitals were phased in. Actually, DRG had
its genesis in the Yale School of Public Health. The
original system identified categories of diagnosis
which could be interrelated on the basis of consump-
tion of hospital resources. One of the students at that
time was later to become New Jersey State Com-
missioner of Health and, virtually, the czar of health
406
and hospital reimbursement in New Jersey.
In 1976, the United States Health Care Financial
Agency awarded the New Jersey Department of Hea i
a three million dollar grant to explore alternatives >
the per diem system of hospital reimbursement.
It should be no surprise to anyone that DRGs hc;:|
become the law of the land. The actual intent of t ‘
original grant was to devise a new method of reijl
bursement for inhospital treatment. In the first fla
years of DRG, many hospitals did very well financial
and very few did poorly. In fact, early on, several hos
tals made inordinate amounts of money. Sources w>
served in the New Jersey State Department of Heai
let it be known that this device was used to make t a
system seem palatable and also to make it political
acceptable.
We must beware of comparisons of the New Jer y
system with the federal plan because there are marl 1
and rather critical differences between them. Soon > i
will see why we in New Jersey should be grateful t!ji
we have a waiver from the federal system.
There are three statements concerning DRGs in NjV
Jersey which can be agreed upon: ( 1 ) The DRG systh
is implementable. In other words, the prospective reir
*This paper was read in part at the Annual Meeting of e
American Orthopaedic Association, The Homestead, >[
Springs, Virginia June 27, 1983.
‘‘Correspondence may be addressed to Dr. Rineberg at 3
George Street, New Brunswick, NJ 08901.
I
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERU
ursement system based on diagnostic groups by case
lix can be used as a basis for hospital reimbursement.
>) Start-up costs are high. Additional medical record
ersonnel must be hired. They must code the medical
hart in such a way as to maximize potential reim-
ursement. Hospitals must hire DRG coordinators,
eretofore unknown professionals, who demand
ilaries of up to $35,000. This is just the start. This
oes not include additional costs for developing soph-
ticated software for comparing clinical activity with
nancial performance— essential and very expensive.
1 addition, fees may have to be paid to special legal
)unsel when engaged to develop appeal documents
milar to those used in public utility cases. The Big
r accounting firms have created divisions dedicated
' helping hospitals take full advantage of this new
imbursement system. (3) The system’s efficiencies
*e yet to be confirmed. No one knows whether the
stem has saved money, can save money, is wasteful,
harmful, is helpful, or is a combination of all three.
Interestingly, the important studies of the early years
DRG are seriously in arrears. Conclusions as to
hether or not New Jersey exceeded the cap allowed
ider the federal waivers awaits the rate appeal pre-
ss for the years 1979 to 1982 which are not com-
eted.
Six major items differentiate the New Jersey system
3m the federal system: (1) The system is limited to
'edicare inpatients and does not include other payors.
|j) Nonmedical indigency costs are not included. (3)
I rect medical education costs are a “pass through”
1 th the indirect costs given only special consider-
:ion. (4) Although capital and construction costs are
I ssed through as a separate item, there is a potential
i;k of retroactive denial of these expenses beginning
larch 1983. (5) Outliers are limited to not less than
bercent or more than 6 percent of the total allowed
RG reimbursement. (6) Eventually, all acute care hos-
f .als in the country will be based upon the same
smdard rate and adjusted only on the basis of geo-
E'aphic area, that is indigenous labor costs.
n New Jersey, all carriers are charged the same
nount for the same diagnosis, whether they be Medi-
ae, Medicaid, or any other payor. Federal DRG is
liitedjust to Medicare inpatients. Previously in New
irsey, we had a system in which different carriers
\ re paid differential rates. Some were regulated while
ners were not. Cost shifting was the rule. Although
federal system has been critical of cost shifting in
|p past, their introduction of prospective reimburse-
ment only for Medicare will serve to further promote
t s activity. It will allow HCFA to look like it is saving
cilars while in the terms of the real world, this may
r t be factual. In fact, bills to other carriers and indi-
vluals could skyrocket.
indigency costs are factored into the New Jersey re-
imbursement formula. In other words, the DRG reim-
trsement for each hospital has taken into eonsider-
apn a portion of the cost associated with patients
Lable to pay hospital bills. This additional markup
fi tor is not dissimilar to what occurs in other busi-
i >ses. As an example, when you purchase shaving
am the cost includes the shopkeeper's loss due to
P ential damage, pillage, or theft. No provision, how-
° r, has been made under the federal DRG to make
* . 81— NUMBER 5— MAY 1984
up for this type of loss. This should have significant
impact upon both the urban hospitals and the teach-
ing hospitals who have experienced an increasing in-
digency load. This matter has not yet been fully re-
solved and hopefully when the regulations are
promulgated at the end of the summer, a more en-
lightened posture will be brought forth.
Direct medical education costs have been a “pass
through" irrespective of classification, i.e. major or
minor teaching hospitals. Although this “pass
through” remains intact in both the New Jersey and
federal systems, the New Jersey Hospital Ratesetting
Commission has expressed grave concern as to its
continued support of this “philosophy.” In fact, they
have recommended the creation of yet another com-
mission to review the cost of medical education and
who should be responsible for payment. Reimburse-
ment for medical education by Washington-based
regulators may become a reality and include limitation
of reimbursement in different specialties, for different
educational needs, and for different types of medical
education programs. This is occurring at a time when
the total financial pot is fixed and shrinking and with
state and federal legislators continuing to seek further
ways to reduce health care costs. The current “pass
through” for residents’ salaries is generous, but this
largess must be considered soft money.
Capital and construction costs under the New Jersey
experience are considered a “pass through.” The feder-
al legislation mandates that HHS perform a study to
determine method of reimbursement for capital re-
lated cost (which includes construction). The study
may go on for 18 months. There is no assurance that
capital projects including purchase of new technology
after March 1, 1983, will be funded. With a single
stroke, the secretary of HHS could throw our hospitals
of the future into a chaotic state.
Outliers are the part of the problem which may affect
both hospitals and physicians the most in the future.
Under the DRG scheme, there are 467 different groups.
Outliers are patients who display inordinate consump-
tion of hospital resources either in terms of clinical
services or length of stay when compared with patients
who possess similar medical attributes. Outliers are
figured separately and adjusted by a separate formula
This gives hospitals a method of fair reimbursement
for a patient who consumes resources at an inordinate
rate. This may include but is not limited to the com-
plicated total hip revision, severe poly-trauma or
cerebral palsy victim who requires a myriad of possible
procedures. Outliers are identified not only by com-
plicated and nonconforming diagnosis but also by a
hospital stay which severely deviates from the norm.
Approximately 35 percent of New Jersey’s patients
are outliers for whom hospitals are paid on a sepa-
rate basis. New Jersey outliers generate approximately
40 to 50 percent of the funds allocated to the hospitals.
Dropping this 35 percent outliers to the 5 or 6 percent
mandated under the federal law will create some rather
stringent problems on the provision of patient care.
Virtually all patients will be assigned to a diagnostic
group regardless of how they compare to the normal
within that DRG. The patient who will be high cost to
the hospital and should but could not be placed in an
outlier category will be most unwelcome by the hospi-
407
tal administrator. For instance, the poly-trauma no
longer may be admitted to the community hospital.
That patient will be transferred to minimize financial
loss. The end result will be regionalization. Perhaps
that will be good, however, it will present the possibility
that other parts of the system as we now know them
will have to be changed.
The young orthopedist with a strong inclination for
traumatic spine surgeiy will no longer have the ability
to set up practice where he wants, but will be forced
to stay near the large center. He will become the direct
competitor of his teachers, which could increase the
friction between the student now turned competitor
and the teacher. How this will affect medical education
and medical practice in the future cannot be de-
termined at the present time but it certainly bears
watching.
The patient who will be high
cost to the hospital and
should but could not be
placed in an outlier
category , will be most
unwelcome by the hospital
administrator.
Another major problem is uniform reimbursement
to all hospitals. Veiy soon all hospitals in the United
States will receive the same amount of money for each
diagnosis with slight regard for labor differential. This
will be irrespective of the hospital’s mission, geogra-
phy, or special care consideration. There will be no
adjustment for severity or complexity of the disease.
This formula could have dire effects on dedicated
tertiary care facilities. It carries with it the potential
of threatening hospitals specializing in veiy com-
plicated and expensive problems.
As originally stated, there are no factual answers to
the question, “Has DRG worked in New Jersey?” There
is no evidence at the present time under any system
that there are any differences in the way individuals
practice before or after DRGs. Rumors that hospital
administrators have stalked the halls trying to oust
patients are not true. The anecdotal evidence of pa-
tients being forced out by the hospitals has yet to be
substantiated. Likewise, claims of cost savings are yet
to be proved. Reduction in the average length of stay
again is yet to be proved. Efficiencies in the institu-
tions and how they manage their affairs is yet to be
proved.
But the system may have merit. It gives those -
sponsible the ability to ratchet down the system. It ci
be used to coerce early discharge and make one thi <
twice before ordering expensive or duplication of kl
oratory or x-ray examination. It certainly will ma =
obsolete the phrase, “Let’s do it for completeness sak '
It can slow and hamper innovation. DRG coordinate?
review major equipment requests to determi;
profitability to the hospital. Administrators as well ?
colleagues carefully will examine new requests r
utilization of resources especially those in which th< ?
is potential for loss.
Standard delivery of care will have to be accepd
most readily. Deviations will be questioned. Simp,,
straightforward, and uncomplicated cases will be ,i
favor while the complicated and the complications s
well will become close to unacceptable.
To some it may seem mind boggling that the Ni
Jersey model which is unproved has been rapidly c;:
seminated. This, however, is acceptable in busin s
and will become more acceptable in government. Mc|r
modifications, however, have been made to a mo:i
which remains questionable and this may have cl
consequences in terms of health care delivery rfr
medical education. They bear careful monitoring, i
The federal and the New Jersey versions of DRG h e;
serious problems. It is new, it is scary, and it is thryl
ening. Nonetheless it is the only alternative plant
change the current per diem method which has pro c
itself to be wasteful. There soon may be a cap on m< i
cal expenses in the United States especially when
are spending 300 billion dollars per annum. This
ages to 86,000 for a family of four.
Certainly a part of the financial pot will go to ho;
tals while the rest will go to physicians. Savings in i
sphere could lead to less frugality in the other
pecially if physicians act in a responsible manner, e
are living in what Peter Drueker has termed “turbu! it
times.” Major progress will be designed in econom 5,
business, and government and implemented withit
experimentation.
Medical leadership in New Jersey has decidec a,
mount a campaign against the DRG system. This ny
prove unfortunate. They have not yet come up wit a
substantial substitute. Reintroduction of the old )•
workable system may lead to a great deal of thrash ig
and will be nonproductive.
True cooperation in this system is necessary er
tween both physician and patient and physician d
hospital and though the system is rough at the prec
time, modifying it may lead to a system which ccjll
save money and continue to allow the highest qu;ty
medical care.
T
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERJ f
408
COMMENTARY: DRG—
the Executive Director’s View
Vincent A. Maressa, j.d., lawrenceville*
The DRG program and its enabling legislation are so flawed that
there is no chance for success. Yet , at least by following the
present policy on DRG , MSNJ will not have collaborated in the
destructive course that will result when the system collapses.
i
Overall, it would appear that Dr.
Rineberg’s article (page 406) is
fairly consistent with the Medi-
cal Society of New Jersey’s policy in recognizing that
the DRG program is not working. He departs from the
Society policy by urging cooperation and modification
of the DRG program so that it might save money and
assure the availability of quality care.
From my perspective, the DRG program and its
Enabling legislation are so flawed that no modification
[butside of totally dismantling the entire system and
rormat can or will produce a reasonable chance for
Ipuecess. The DRG concept assumes that clinical aver-
ages will occur, will be predictable, and will be a valid
mechanism upon which to predicate payments for
aospital services. None of that has been proved so we
Ghould examine what we do know.
“Averaging” sounds pleasant enough but generally
las no basis in fact. The average American family has
1.79 children. That is absurd as a fact unless the aver-
age American woman always is pregnant. The average
)remium for physicians insured through the Medical
nter-Insurance Exchange of New Jersey for pro-
fessional liability is $6,850. There is no class of prac-
ice that pays that rate. So much for averaging!
The DRG program has established its invalidity by
he fact that even though liberal trim points are used,
15 percent of the cases are falling outside the system.
The enabling legislation is another matter. It allows
hospitals to place a number of items not directly re-
lated to patient services into their base rate. It also
allegedly compensates for indigent care and requires
payors to pay at the same rate. At the same time, it
allows discounting to Blue Cross. The state legislature
could not force the federal government to do anything.
The Health Care Financing Administration, therefore,
gave us the DRG program but capped its liability. The
system does not really compensate for indigent care.
By virtue of statutory cost shifting, it simply allows
hospitals to charge others more to make up their defi-
cits. Such a concept is self-defeating because it
produces higher rates for the same DRG in the hospi-
tals with significant indigent patient populations as
opposed to other hospitals. The paying population now
has begun to realize this and the business community
actively is steering patients away from these hospitals.
As more and more paying patients go elsewhere, the
financial base of the high indigent hospital de-
teriorates. The Health Department’s answer is to con-
tinue the cost shift by letting the hospital charge more
for its services.
Blue Cross is allowed a 10 to 15 percent discount
under the program. Self-insureds such as union and
welfare funds, can pay charges or DRGs, whichever are
lower since they are not “insurance companies.” In-
surance companies are paying DRGs most of the time.
*Mr. Maressa is the Executive Director, MSNJ.
T>L. 81— NUMBER 5— MAY 1984
409
but really do not have to, according to the Department
of Insurance. All they must do is honor their policies
which almost always cover “incurred or actual
charges." Once these carriers realize what their op
tions are, they will pay DRC. or incurred charges,
whichever are lower. The federal government is into
this situation on its own terms. IfDRGs in other states
produce a lower rate, I am sure the “waiver" will be
extinguished. The new “waiver” also requires that
HMOs be allowed to discount even though they do not
fit the discount criteria established in our state stat-
utes. The best one can say about the effect of the
statute is that it cannot be implemented.
All our readers know that comparing our rate of cost
increase to national averages is silly since we have
always been below them. For the past six years prior
to DRG, we averaged 3.5 percent below the national
average. The first year of DRG, we came in 3.4 percent
below the national average. The next year we came in
4.7 percent below the national average. That looks en-
couraging until you realize that the national average
of cost increase in that particular year was 1.7 percent
greater than the established trend had been.
The most telling statistic which the Department cj
Health does not want to discuss, however, is the in
creased price to the patient. According to the Depart
ment of Health, in the first year of DRG net patien
service revenue increased 22.6 percent. Since the cosU
increased 13.6 percent, it is fair to assume the cost t
the public went up about 36 percent if not more. Th
next year, the net revenues increased by 14.8 pereen,
and costs went up 14.0 percent for a change in prici
to the patient of at least 28.8 percent if not more, i
I do not see any way for MSNJ to effect any reasor
able changes in the system. The state and federal go'
ernments hardly can be expected to admit error. Whe
the system collapses they likely will point to the med
cal profession. At least by following the present cours
we will not have collaborated in the destructive cours
that resulted. Most of the factors producing these eos
escalations are well beyond the control and manage
ment of the practicing physicians. Physicians are n
more responsible for what has occurred than they ar
for the cost of auto insurance in this state.
f
:
!
!
I
|
1
I
:!
..1C
410
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
IMAGING: An APPROACH TO THE
Diagnosis of Cholecystitis*
Louis S. Zeiger, m.d., camden**
What imaging procedure should you consider when suspecting
gallbladder disease ? This article discusses the use of
ultrasonography and hepatobiliary scan.
What imaging procedure should
you consider when suspecting
gallbladder disease? This article
ill discuss the use of ultrasonography and hepatobil-
ry scan.
LTRASONOGRAPHY
Ultrasonography of the gallbladder using high fre-
aency sound waves in the MHz (megahertz) range
sualizes the gallbladder as a fluid-filled, echo-free
gan (Figure 1). The image represents the distribu-
)n of tissue acoustic impedance. The presence of
hoes in the gallbladder which are mobile and cause
minished sound transmission are diagnostic of
lolelithiasis. The accuracy of gallstone detection is 95
rcent using ultrasound examination (Figure 2). Gall-
pnes as small as 2 to 3 mm have been detected,
andard x-ray oral cholecystogram has a 90 percent
1 erall accuracy in patients with a visualized
jillbladder. However, there are many reasons why the
i llbladder may not be visualized: nausea, vomiting, or
•arrhea The ultrasound procedure is the most ac-
• rate, noninvasive technique to establish the
• agnosis of cholelithiasis, which invariably is as-
iciated with chronic cholecystitis. In addition, in the
] tient with suspected biliary obstruction, the ultra-
} und examination is a sensitive indicator of intra- or
'trahepatic bile duct size and, therefore, the site of
' struction. In the presence of chronic cholecystitis,
I,
i)L. 81— NUMBER 5— MAY 1984
the diagnosis of acute cholecystitis is not reliably made
by ultrasound. Pathologically, the majority (98 percent)
of surgically verified acute cholecystitis is associated
with cystic duct obstruction. The presence of a
thickened wall greater than 5 mm and a cystic duct
stone are rarely seen by ultrasonography study.1
HEPATOBILIARY SCAN
The study of choice in the diagnosis of acute
cholecystitis is hepatobiliary scanning (HBS) with
Tc99-disofenin or cholescintigraphy. If serum
bilirubin is less than 8 mg/dl, the procedure is valid.
The radionuclide tracer, Tc99-disofenin, when in-
jected intravenously, is selectively excreted by the
hepatocytes into the biliary system. Approximately 90
percent of the tracer is excreted into bile if the serum
bilirubin is normal. By 20 to 30 minutes after the
injection, the gallbladder and common duct are seen
clearly (Figure 3A) and cystic duct obstruction has
been excluded. If the gallbladder is not visualized by
3 hours after injection and the common duct seen,
‘IMAGING is a new column to be presented in The Journal
under the direction of Judith K. Amorosa. M.D., Director of
Medical Education, Department of Radiology, UMDNJ-
Rutgers Medical School.
**Dr. Zeiger is Chief, Division of Nuclear Medicine, Cooper
Hospital/University Medical Center, Camden. Cor-
respondence may be addressed to Dr. Zeiger. Cooper Hospi-
tal/University Medical Center, One Cooper Plaza, Camden, NJ
08103.
41 1
1574276
11/16783
CBD
Figure 1— Ultrasound of the gallbladder. Left lateral de-
cubitus projection demonstrates an echo-free gallbladder (G).
Figure 2 — Ultrasound of the gallbladder. Longitudinal projec-
tion demonstrates echoes secondary to gallstones (open
arrow head). Curved arrow points to so-called acoustic
shadowing, area beyond stones where sound is not trans-
mitted.
GB 2/03/84
Figure 3A — Hepatobiliary scan Tc99-disofenin normal study.
Anterior view 30 minutes after injection visualizes the gall-
bladder (GB), as well as, medial to it, the common duct and
small bowel activity.
cystic duct obstruction is implied (Figure 3B).
Weissman et ai.2 studied 352 patients prospectively
Figure 3B — Hepatobiliary scan Tc99-disofenin. Anterior vie
at 45 minutes after injection fails to visualize the gallbladdc
but the common bile duct (CBD) and small bowel (SB) a
seen. The study is diagnostic of acute cholecystitis.
I Patient Population
for acute cholecystitis with the following results: 1 i
Gallbladder visualization accurately excluded th
412
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
diagnosis in 99.2 percent; the false negative rate was
.8 percent. 2) Gallbladder nonvisualization (up to 3
hours) confirmed acute cholecystitis in 95 percent of
patients surgically confirmed. That is a 5 percent false
positive rate primarily secondary to severe chronic
cholecystitis.
CONCLUSION
The presence of a normal hepatobiliary scan or vis-
ualization of the gallbladder by one hour excludes the
diagnosis of acute cholecystitis in most patients.
Aealeulous cholecystitis occurs in 1 to 5 percent of all
patients. A normal hepatobiliary scan might be ex-
pected but the observed false negative rate is 1 percent
suggesting a lower incidence (Figure 4).
REFERENCES
1. Shuman WP, et al.: Ultrasonic diagnosis of acute and/or
chronic cholecystitis. AJR 139:61-64, 1982.
2. Weissman HS, et al.: Spectrum of 99m Tc-IDA cholescin-
tigraphic patterns in acute cholecystitis. Radiology
138:167-175, 1981.
3L. 81— NUMBER 5— MAY 1984
413
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414
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Current Nutrition: Diet And Nutrition
in Chronic Renal Failure*
Norman Lasker, m.d., Newark**
Signs and symptoms of uremia are related to products of protein
metabolism . Hence , protein restriction is the cornerstone of
nutritional management inpatients with chronic renal failure.
Protein restriction must be associated with a high caloric intake
to be effective.
T
here are three basic modalities
for the treatment of patients
with established chronic renal
ailure: diet, dialysis, and transplantation. Of the three,
liet is the most pervasive since it is applied inde-
tendently or in conjunction with the others, i.e. to a
arge extent the success of chronic dialysis depends on
he patient’s adherence to a strict dietary regimen. The
chronic dialysis patient does not enjoy optimal good
realth and the transplantation patient is subject to the
mcertainties of kidney procurement, rejection, and
he serious side effects of immunosuppressant drugs.
|rhe suggestion that an appropriate diet can slow the
Progression of chronic renal failure to the stage where
llialysis and transplantation are required, enhances
he importance of careful dietary and nutritional man-
agement.
The objectives of the nutritional management of pa-
tents with chronic renal failure include: prevention
md control of uremic signs and symptoms; decrease
he progression of renal damage; and obtain the
receding without the development of protein, calorie,
itamin, and mineral deficiencies.
ROTEIN AND CALORIES
Uremic signs and symptoms are related, in large
art, to products of protein metabolism, including
olypeptide middle molecules, urea, guanidinosuccinic
cid, methyl guanidines, methylamines, and phenolic
OL. 81— NUMBER 5— MAY 1984
acids. Proteins also are the source of hydrogen ions,
potassium, and phosphorous, which tend to ac-
cumulate and produce toxic effects in renal failure.
Therefore, the basis of diet therapy is protein restric-
tion.
Thomas Addis’s1 suggestion that protein restriction
slows the progression of renal failure has been cham-
pioned by Barry M. Brenner and his associates2 who
hypothesize that a protein-induced increase in single
nephron glomerular filtration and permeability facili-
tates the filtration of plasma proteins. The accumula-
tion of plasma proteins in the glomerular mesangial
cells stimulates them to produce glomerular sclerosis.
Since dietary restriction of phosphate decreases the
progression of experimental renal failure through de-
creasing hyperparathyroidism and/or preventing in-
terstitial deposition of calcium phosphate crystals,
some of the beneficial effects of protein restriction may
be due to associated phosphate restriction.3
Renal histology in chronic renal failure is
nonspecific and one cannot predict the rate of pro-
*This column is prepared under the direction of Herman
Baker, Ph.D., Professor, Preventive Medicine/Community
Health and Medicine, UMDNJ-New Jersey Medical School.
**From the division of nephrology, UMDNJ-University Hospi-
tal, Newark. Correspondence may be addressed to Dr. Lasker,
Medical Science Building, Room 1-514, UMDNJ-University
Hospital, 100 Bergen Street, Newark, NJ 07103.
415
gression of renal disease by its etiology. However, the
rate of progression is consistent in any individual pa-
tient. A graph plotting the reciprocal of the serum
creatinine against time gives a descending straight
line curve and can be used to monitor the effects of
dietary manipulations on the progression of the renal
disease.4 Using this method, Maschio et al. have shown
a low protein-phosphorous diet decreases the pro-
gression of chronic renal disease in azotemic patients
with serum creatinines ranging from 1.60 to 5.40 mgm
percent.5
It is critical to provide the benefits of protein restric-
tion without producing protein-calorie malnutrition
and depletion of vitamins and minerals. Approximately
70 percent of the protein should be of high biological
value defined as proteins containing a high percentage
of the essential amino acids in the proportions re-
quired by humans to allow their efficient incorpora-
tion into body proteins. High biological protein foods
are eggs, milk products, meat, poultiy, and fish. Pa-
tients with renal failure frequently are anorexic be-
cause of the accumulation of uremic toxins, medi-
cations, and emotional depression. The anorexia is ac-
centuated by dehydration and acidosis. A vicious cycle
may develop whereby anorexia and emesis resulting
from uremic toxicity dehydrate the patient and further
decrease renal function. Temporary measures such as
intravenous fluids or acute peritoneal dialysis may be
required to break the cycle and allow the acceptance
of the therapeutic diet.
A high caloric intake of at least 35 Kcal/kgm body
weight is essential to the success of a low protein diet.
Inadequate caloric intake promotes protein break-
down by gluconeogenesis and causes negative nitro-
gen balance. The protein restricted diet must be com-
patible with the patient's tastes to encourage his com-
pliance and insure adequate calorie intake. High
calorie, low protein supplements such as Hycal®, Poly-
cose®, or Controlyte® may be required to meet the
calorie requirement. The protein and calorie intake
may have to be increased during periods of stress such
as gastrointestinal bleeding, surgeiy, trauma or infec-
tion. This may necessitate hyperalimentation by
gastric feeding tube or central vein. Protein losses in
the urine can be replaced by increasing the protein
intake by 1.4 gm for each gram of protein in the urine
based on 70 percent protein utilization.6
Although protein-restricted diets previously were
started when patients developed signs and symptoms
of uremia the possible role of protein in accelerating
the progression of renal failure indicates an earlier use
of these diets. This diet also should be considered in
any azotemic patient with chronic renal failure and an
increasing serum creatinine. The level of protein in-
take is based on residual renal function as well as the
clinical picture; thus, it may be necessary to decrease
the protein intake if the patient is symptomatic at
intake levels indicated by the creatinine clearance
(Table 1).
As creatinine clearance decreases below 6 ml/min,
it may become difficult to maintain the patient free of
uremic signs and symptoms on a 40 gm, high-
biologieal value diet. Restricting the protein intake
below this level results in a less-appetizing diet with
poor patient compliance and the development of pro-
TABLE
1
Protein Restriction
in Relation to
Residual Renal Function
Protein Intake
Creatinine Clearance
Gms/kgm/day
mls/min
0.8*
15 to 30
0.6*
6 to 15
0.3 + 0.2 of essential
< 6
L-amino acids + histidine
* = > 70 percent of high biological value protein.
tein and caloric malnutrition.7 Bergstrom and his as-
sociates have utilized an unselected protein-poor diet
of 16 to 20 gm supplemented with 10 to 20 gm of
essential L-amino acids plus histidine as the acetate
salt (Aminess®).8
By allowing low-quality protein, the diet is more
varied and better patient compliance is achieved.
Clinical results are impressive with the abatement of
uremic symptoms and improvement in the patient’s
strength and vigor.*
Despite the protective effects of low protein diets,
these patients eventually will need dialysis or trans-
plantation. This is indicated when the patients develop
congestive heart failure despite salt restriction and
large doses of "Loop" diuretics, pericarditis, bleeding,
neuropathy and persistent nausea vomiting, and
malaise. (Correctible factors such as obstruction,
prerenal failure, and drug-induced decreases in renal
function should be considered first.)
Protein-restricted diets tend to be boring but patient
compliance can be enhanced by a team approach in-
volving the patient and family with physicians, dieti-
tians, nurses, and social workers. The physician
should instruct the patient and his family on the
rationale of the diet and stress its importance by
checking the patient’s compliance at each visit. The
dietitian should adjust the diet within the restricted
guidelines, but attempt to select foods which are to the
patient’s liking. The dietitian excels in obtaining the
dietary history, establishing a patient’s caloric and
protein requirements on the basis of deviation from
ideal body weight and nutritional status, and trans-
lating that data into a meal plan. Nutritional status
may be assessed from measurements of height and
weight, skin fold thickness, midarm muscle circumfer-
ence, and growth in children. Useful laboratoiy guides
include the level of total serum proteins, serum
albumin, serum transferrin, and C3 (complement).10
Other laboratory parameters such as decreased ratios
of essential to nonessential amino acids are not gener-
ally available. The adherence of the relatively stable
patient to the protein and caloric requirements of the
diet also can be monitored by examining the
BUN/ereatinine ratio. Since the serum urea level main-
ly is based on protein intake, protein metabolism, and
renal function while the serum creatinine level mainly j
is determined by renal function, the relation between
the two is a useful index of protein intake. Other fac-
tors influencing the ratio such as increased protein
*The use of keto analogues of the essential amino acids to
decrease nitrogen accumulation still is experimental; the
analogues are not available commercially.9
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
416
16
TABLE 2
14
Vitamin Supplements in Chronic Renal Failure
12
Dose
JZ>
Vitamin
mgm/ day
10
Thiamin
1.5
Riboflavin
1.8
8
s' s' s'
Pantothenic acid
5
s'
Niacin
20
6
Mean and
95% Confidence Limits
Pyridoxine
5
4
Ascorbic acid
100
^ s'
Folic acid
1
2
Bl2
(none necessary)
1 | | | 1 1 1 1 1
Berocca® is a water soluble vitamin which provides these
” 0
10 20 30 40 50 60 70 80 90
vitamins.
Protein Intake (gm/day)
Figure — Direct relationship between blood urea nitrogen
(BUN)/serum creatinine ratio and protein intake in stable
chronically uremic men.11
catabolism, dehydration, extremely small muscle mass,
and advanced hepatic disease usually are obvious. 1 1 A
stable, chronically uremic patient on a 40 gm protein
1 intake should have a BUN/creatinine ratio of approx-
imately 6 while a ratio greater than 7.5 suggests a
higher protein intake (Figure).
When the thirst mechanism is intact, water intake
usually is dependent on salt intake. A pathological in-
crease or decrease in water intake is indicated by hypo-
or hypernatremia Patients usually will remain
eunatremic if allowed free access to water providing
there are no superimposed problems such as cardiac
failure, administration of potent “Loop” diuretics, or
inappropriate intravenous fluids.
POTASSIUM
VITAMINS
Most of the data indicating clinically significant vit-
amin deficiencies in chronic renal failure were ob-
tained in patients on chronic dialysis. 1 2 These deficien-
cies involve water soluble, nonprotein-bound vitamins
which are removed by the dialytic treatment. However,
potassium-restricted diets may be low in water soluble
vitamins and supplements may have prophylactic
value (Table 2). Fat soluble vitamins are not rec-
ommended routinely because their blood levels usually
are normal or elevated and they are potentially toxic.
Blood levels of 1-25 dihydroxyeholecalciferol, the active
metabolite of vitamin D, are low in the late stages of
renal failure, but supplements usually are not given
until the patient is on dialysis because of the dangers
[of calcium-phosphatase precipitation in blood vessels
and organs (vide infra).
SODIUM AND WATER
The George Schreiner concept of "homeostenosis” in
patients with chronic renal failure indicating a rela-
tively fixed renal salt and water excretion which is only
minimally responsive to acute changes in intake is
very appropriate.13 A good guide to the sodium require-
ment is the measurement of 24-hour urinary sodium
jexcretion after three days of a constant 2 to 3 gm
'sodium intake. Salt intake should be set at the maxi
I
mum level which does not lead to heart failure or
pulmonary edema. Rapid fluctuations in body weight
usually are due to changes in salt and water intake arid
not caloric balance. Sympatholytic agents and
vasodilators may be better therapy than severe salt
restriction for hypertension in some patients with
Ichronic renal failure because of the danger of
hypovolemia and decreased renal function when the
[sodium excretion is excessive.
Potassium restriction below the 2 to 3 gm provided
by a low protein diet usually is not necessary.
Potassium excretion is maintained at this level despite
a marked fall in renal potassium filtration by adaptive
increases in Na+ - K+ ATPase activity of renal tubular
and gastrointestinal cells. Hyperkalemia may occur in
the presence of oliguria, marked dietary indiscretions,
K+ retaining diuretics, or increased catabolism and
tissue breakdown. The prostaglandin-inhibiting anti-
inflammatoiy agents may decrease renal blood flow,
lower renin-aldosterone production, and potassium ex-
cretion.
Hyperchloremic acidosis associated with hyper-
kalemia (type IV renal tubular acidosis) may be seen
in mildly azotemic patients with diabetes mellitus and
decreased autonomic innervation of the jux-
taglomerular apparatus producing hyporeninism and
hypoaldosteronism. A similar picture is seen in some
patients with chronic interstitial renal disease as the
tubules no longer are responsive to aldosterone. The
acidosis and hyperkalemia may respond to the
potassium lowering effect of “Loop” diuretics, sodium
bicarbonate administration, potassium exchange
resins, and poorly absorbed polysaccharides such as
Sorbitol®. An aldosterone substitute such as Florinef®
may be indicated in the patients with low renin and
aldosterone who are not in heart failure or markedly
hypertensive.
ACIDOSIS
Metabolic acidosis in chronic renal failure usually is
caused by decreased ammonia production due to lack
of functioning tubular cells. The associated high anion
gap is due to the retention of inorganic “acid” anions
such as phosphate and sulfate. The hydrogen ions
associated with these fixed acids are acutely buffered
by bicarbonate, but on a chronic basis much of the
70L. 81— NUMBER 5— MAY 1984
417
buffering occurs in the bone with the liberation of
calcium carbonate and the development of osteopenia
To prevent this sequence, it is recommended that the
serum bicarbonate be maintained at the level of 20
MEq/liter with sodium bicarbonate supplements. So-
dium bicarbonate more readily is excreted than so-
dium chloride in these patients and is less likely to
produce congestive heart failure.
CALCIUM AND PHOSPHOROUS
As the glomerular filtration rate decreases, phos-
phorous is retained. The elevation in serum phos-
phorous lowers the serum calcium level (the product
of [Ca++] x [P04=] usually is maintained in 30 to 40
range) which in turn stimulates the parathyroid
glands to hypertrophy. The low serum calcium concen-
tration also may be a reflection of decreased calcium
intake on a low protein diet and a decrease in the renal
production of the active vitamin D derivative, 1-25
dihydroxycholecalciferol. The decrease in vitamin D
activity inhibits calcium absorption from the intestine
and its release from bone.
Therapy is directed to lowering phosphorous intake
by a low protein diet with limited milk products. De-
spite the low phosphorous diet, aluminium hydroxide
and aluminium carbonate antacids usually are neces-
sary to reduce phosphorous absorption and achieve a
normal phosphorous level. Calcium supplements, such
as 2 to 6 gm of calcium carbonate (40 percent calcium),
are indicated because of the low calcium content of the
protein restricted diets and the decreased vitamin D
activity. However, calcium supplements should not be
given until the serum phosphorous is reduced to the
normal range of 3.5 to 4.5 mgm/dl. Allowing the
ealeium-phosphorous product to rise above 50 may
increase the rate of progressive renal damage as well
as result in extrarenal calcification.
Active vitamin D metabolites usually are not given
to patients with chronic renal failure who are not on
dialysis because of the dangers of intra- and extrarenal
calcium phosphate precipitation. Since increased
parathyroid hormone levels may contribute to many
uremic signs and symptoms such as bone disease,
myopathy, anemia, pruritis, encephalopathy, and sex-
ual dysfunction, it is important to maintain a normal
serum calcium level. This best is achieved by lowering
the serum phosphorous with a low phosphorous in-
take and aluminium antacids followed by calcium sup-
plements, if needed.
SUMMARY
The signs and symptoms of uremia chiefly are re-
lated to products of protein metabolism. This fact and
the possibility that the progressive nature of renal dis-
ease is related to protein intake makes protein restric-
tion the cornerstone of nutritional management in
patients with chronic renal failure.
Protein restriction must be associated with a high
caloric intake to be effective. Water soluble vitamin
supplements are indicated in chronic renal failure be-
cause of their low level in potassium restricted diets.
Aluminum antacids are required to control the high
serum phosphorous levels resulting from decreased
renal phosphate excretion. Elevated serum phos-
phorous levels, decreased dietary calcium intake, and
low vitamin D activity result in hypocalcemia and sec-
ondary hyperparathyroidism. This sequence should be
prevented with phosphorous binding antacids and
calcium supplements. The role of vitamin D in non-
dialysis patients is controversial.
REFERENCES
1. Addis T: Glomerular Nephritis: Diagnosis and Treat- ;
meat New York, NY, Macmillan, 1950.
2. Brenner BM, Meyer FW, Hostetter FH: Dietary protein
intake and the progressive nature of kidney disease. N Engl
J Med 307:652-659, 1982.
3. Ibels LS, Alfrey AC, Haut L, Huffer WE: Preservation of
function in experimental renal disease by dietary restriction
of phosphate. N Engl J Med 298:122-126, 1978.
4. Mitch WE, Walser M, Buffington SA Lemann J: A simple j
method of estimating progression of chronic renal failure, j
Lancet 2:1326-1328, 1976.
5. Masehio G, Oldrizzi L, Tessitore N, D’Angelo A Valvo E,
Lupo A, Loschiavo C, Fabris A Gammaro L, Rugiu C, Panzetta
G: Effects of dietary protein and phosphorous restriction on
the progression of early renal failure. Kidney Int 22:371-376,
1982.
6. Giordano C: Protein restriction in chronic renal failure.
Kidney Int 22:401-408, 1982.
7. Koppel JD, Sorensen MK, Cobum JW, Gordon S, Rubini !
ME: Controlled comparison of 20-g and 40-g protein diets in
the treatment of chronic uremia Am J Clin Nutr 21:553,
1986.
8. Bergstrom J, Furst P, Noree LQ: Treatment of chronic
uremic patients with protein-poor diet and oral supply of
essential amino acids. I. Nitrogen balance studies. Clin Neph
3:187-194, 1973.
9. Walser M: Nutritional management of chronic renal fail-
ure. Am J Kidney Dis 1:261-275, 1982.
10. Kopple JD: Nutritonal Management, in Massry SS,
Glassock RJ (eds). Textbook oj Nephrology. Baltimore, MD,
Williams and Wilkins, 1983, pp. 8.3-8.13.
1 1. Kopple JD, Cobum JW: Evaluation of chronic uremia
Importance of serum urea nitrogen, serum creatinine, and
their ratio. JAMA 227:41-44, 1974.
12. Lasker N, Harvey A Baker H: Vitamin levels in
hemodialysis and intermittent peritoneal dialysis. Trans Am
Soc Artif Intern Organs 9:51-56, 1963.
13. Schreiner G: Personal communication.
1 1
I
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
418
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But they really have a team behind them*
These physicians spend most of their day working We also believe that all medical societies —
independently in a one-to-one doctor/patient rela- county, state, and national — have certain tasks that
tionship. And chances are that as a physician, the individual physician couldn’t possibly assume —
you do too. and shouldn’t have to.
But even though you can’t see it, there’s a strong Tasks such as keeping government regulations
team supporting and protecting the medical profes- from interfering with your practice by representing
sion, affecting your practice while you see patients, your interests at local and national levels. And chal-
research new drugs or perform surgery. That team lenging regulatory measures that threaten you and
consists of your medical societies. your patients’ interests by mounting legal campaigns
The American Medical Association and your state to defend your rights — up to the Supreme Court if
and county medical societies believe in the value of necessary.
teamwork; that only by working together can we, in Why do we believe that teamwork means so much
the face of an increasingly complex professional en- to all physicians — even those who work “alone”?
vironment, protect your right to make responsible
decisions on how to practice medicine. Because ... IT WORKS.
Join Your
Medical Societies
Today.
For more information, contact your state
or county medical societies, or call the
AMA collect at 312/751-6196. Or return
the coupon below to your state or county
medical society.
□ Please send me information on AMA, county, and state society membership.
□ I am a member of my county and state societies; please send me information
on joining the AMA.
Name .
Street .
. State .
County .
1
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
420
Opinion: Overcoming
Psychic Numbing
Bernard Grossman, m.d., trenton*
Psychic numbing includes defense mechanisms of denial,
suppression, and repression . It allows us to create an
illusion of control, and our society is plagued by psychic
numbing. To overcome psychic numbing we must develop a new
manner of thinking.
Psychic numbing is a phenom-
enon that includes defense
mechanisms of denial, sup-
pression, and repression. It allows us to create an il-
lusion of control over that which we cannot control or
bscape. Through psychic numbing, we avoid issues too
painful or too difficult to confront. Our society is
plagued by psychic numbing. The media provides a
daily tale of rape, murder, brutality, and cruelty.
Eventually, these events are accepted as part of the
fabric of society. Indeed, they become a subliminally
acceptable portion of everyday life. We become im-
munized to the chaos around us. Only when they affect
as directly are we forced to accept the full impact of
these horrors.
“The Day After,” the special television presentation,
stirred controversy. The film was criticized for its
cinematography, character development, associated
media hype, implied political statement, and lack of
Igore. Viewers experienced the implied deaths of
billions, yet some distilled it to an intellectual movie
review— denying the carnage they witnessed. This al-
lows suppression of anxiety which is natural when
viewing such destruction. Lack of anxiety leads to lack
of motivation and any thoughts of activism thereby are
repressed. The result is an intolerable situation. An
issue that should be met with political and social ac-
tivism instead is met with complacency and inactivi-
ty—the results of psychic numbing.
In order to overcome psychic numbing, it is neces-
sary, as Einstein said, to develop a “new manner of
thinking.” Old ways of thinking must be re-evaluated
and changed if nuclear war is to be avoided.
OLD WAYS OF THINKING
1. Deterrence. The concept that “stockpiling” leads
to deterrence only pertains to conventional warfare. In
a conventional sense, more weapons may translate into
more security. However, while it is possible to win a
conventional war, there will be no winners of a nuclear
confrontation. The idea that more “nukes" translate
into more security is a type of nuclear addiction. Like
the drug addict, our society has developed an illusion
of security (more bombs) which actually diverges from
reality (safety). As the addict finds that more heroin
improves a sense of security, so we are under the mis-
taken impression that more bombs improve our secur-
ity. Unfortunately, not only will the Cruise, Pershing,
and MX systems fail to increase our security, but they
serve to heighten tensions by eliciting a Soviet
response of reciprocal buildup. This advanced weapon-
ry reduces the time a launch error can be detected and
corrected. Its installation, while providing an illusion
*Dr. Bernard Grossman is a practicing oncologist/hema-
tologist and he is a member of Physicians for Social Responsi-
bility. Correspondence may be addressed to Dr. Grossman,
408 Bellevue Avenue, Trenton, NJ 08628.
VOL. 81— NUMBER 5— MAY 1984
421
of security, actually is accompanied by an increase in
actual danger and threat to life.
2. Image of the Enemy. Another concept that tends
to foster old ways of thinking is an “image of the
enemy.” To prepare for war, a society must nurture
hatred for its enemy. Once identified, all information
obtained concerning the enemy is selected, distorted,
and reflected in ways that validate the perception of
the enemy’s evil. The psychological term for this is
“projection of the shadow.” Clearly, President Ronald
Reagan utilizes this imagery when he casts Moscow as
“the focus of evil in the modem world.” Nonetheless,
this type of rhetoric is self-defeating and only serves
to increase tensions between the superpowers.
3. Myth of Survivability. The myth of survivability
through civil defense makes nuclear war palatable.
While civil defense measures may have been ap-
propriate for World War II, unfortunately, they no
longer are meaningful in the nuclear age.
Evacuation and sheltering are the main components
of civil defense. Evacuation is impractical for several
reasons: a) missiles can be targeted to places of evacu-
ation; b) impracticality of an organized plan; and c)
lack of time to complete evacuation procedures.
Shelters offer no more hope for survival than evacu-
ation. People who reach shelters following a blast
already would have received lethal radiation doses.
They merely would enter the shelters and die. In the
unlikely event that a shelter could be reached before
a blast occurred, it would serve as a crematorium-
unable to provide protection against the resulting
blast, heat, radiation, and fire storms.
As evacuation and sheltering are unable to protect
the citizemy during a nuclear attack, it would seem
pure folly to endorse any portion of President Reagan’s
plans which have included evacuation to the country
and filling out change of address forms for mail for-
warding.
THE BEGINNINGS OF CHANGE
Once we accept that our old ways of thinking no
longer are applicable in the nuclear age, we then are
ready to accept new ways of thinking and the changes
they will produce. Once realized, new ways of thinking
can lead to assertive action. Each person— including
physicians— can get involved in letter writing and
phone campaigns or financial support of groups and
candidates who espouse a mutually verifiable nuclear
freeze. Physicians should encourage hospital adminis-
trations not to support the civilian-military contingen-
cy plan. As noted by Dr. Jack Geiger at a Physicians
for Social Responsibility Conference in 1980, “Any
physician who even takes part in a so-called emergency
medical disaster planning — specifically to meet the
problem of nuclear attack— is committing a profoundly
unethical act. He is deluding himself or herself, col-
leagues, and, by implication, the public at large into
the false belief that mechanisms of survival in any
meaningful social sense are possible.”
Writing letters to newspaper editors, participating in
organized protests, joining Physicians for Social Re-
sponsibility, speaking out on radio talk shows, and
stimulating discussion on the freeze issue are all
positive, assertive responses which can lead to an in-
creased chance of avoiding a nuclear confrontation.
Through the ballot, representatives can be elected who
recognize our current dilemma and who support an
end to nuclear madness.
For its part, the government should continue to de-!
velop strong conventional forces to counteract threats
to our own security or the security of our allies. Ad-
vancements of this kind effectively can neutralize nu-
merical superiority the Soviets may have in Europe, for
example. Improved communications and espionage
networks can help preserve our security while not
threatening the destruction of the world. While the
abolition of all forms of war would be ideal, it is naive
to think that this is possible in the foreseeable future
and non-nuclear measures to ensure our security
must be pursued.
Former Defense Secretary Robert S. McNamara has
proposed a number of ways to reduce the chances of
nuclear war: 1 ) a negotiated reduction in the ratio of
nuclear warheads to missile launchers; 2) renouncing
the strategy of launching on warning; 3) announcing
a policy of no early first use of nuclear weapons; 4)
strengthening NATO conventional forces; 5) redeploy-
ing our European missiles away from the Soviet border
so as to make them less vulnerable to attack in the
early hours of a conflict; 6) negotiate a nuclear freeze
zone with the Soviets; 7) strengthen nuclear non-
proliferation programs thereby limiting the growing
membership of the world’s nuclear club; and 8) nego-
tiate the establishment of a joint U.S.-Soviet Infor-
mation and Crisis Control Center. Even if a mutually
verifiable freeze is not deemed feasible by the current
administration, the above proposals certainly would be
a move in the right direction.
Jonathan Schell summed up our choices in the final
paragraph of his book. The Fate of the Earth: "Two
paths lie before us. One leads to death, the other to life.
If we choose the first path— if we numbly refuse to
acknowledge the nearness of extinction, all the while
increasing our preparations to bring it about — then we
in effect become the allies of death, and in everything
we do our attachment to life will weaken; our vision,
blinded to the abyss that has opened at our feet, will
dim and grow confused; our will, discouraged by thej
thought of trying to build on such a precarious foun-
dation anything that is meant to last, will slacken; and
we will sink into stupefaction, as though we were grad-
ually weaning ourselves from life in preparation for the
end. On the other hand, if we reject our doom, and
bend our efforts toward survival — if we arouse
ourselves to the peril and act to forestall it, making
ourselves the allies of life— then the anesthetic fog will
lift; our vision, no longer straining not to see the ob-
vious, will sharpen; our will, finding secure ground to!
build on, will be restored; and we will take full and clear
possession of life again. One day — and it is hard to
believe that it will not be soon — we will make our
choice. Either we will sink into the final coma and end:
it all or, as I trust and believe, we will awaken to thej
truth of our peril, a truth as great as life itself, and,
like a person who has swallowed a lethal poison, but
shakes off his stupor at the last moment and vomits
the poison up, we will break through the layers of our
denials, put aside our fainthearted excuses, and rise
up to cleanse the earth of nuclear weapons.”
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
422
DOCTORS’
NOTEBOOK
Trustees’ Minutes;
UMDNJ Notes; AMNJ
Report; Diagnostic
Virology Report;
Physicians Seeking
Location in New Jersey
frustees* Minutes
Aarch 18, 1984
A regular meeting of the Board of
'rustees was held on Sunday,
larch 18, 1984, at the Executive Of-
ices in Lawrenceville. Detailed
ijninutes are on file with the sec-
etaiy of your county society. A sum-
nary of significant actions follows:
teport of the President . . .
1) Definition of Health Care Fa-
cility . . . Solicited opinions on a
roposal of the State Department of
lealth to amend the definition of a
wealth care facility for use at meet-
ng of Dr. Kovacs with the Com-
missioner.
2) New Jersey State Society of
Anesthesiologists . . . Approved a
esolution of appreciation to the
Jew Jersey State Society of
anesthesiologists for their un-
iestricted grant of 81,000 to MSNJ.
teport of Executive Director . . .
1) MSNJ 1984 Paid Membership
. . Noted that paid memberships as
f February 29, 1984, totaled 6,420.
2) MSNJ Financial Statements
. . Approved financial statements
f MSNJ for period ending February
:9, 1984.
(3) PRO Request for Proposal and
Regulations . . . Noted that recently
the Health Care Financing Adminis-
tration (HCFA) released materials
relative to request for proposal (RFP)
for PRO contracts and regulations
for the PRO program. The RFP re-
quirements for Medicare waiver
states (New Jersey is a “waived”
state) were released in April.
(4) State Board of Medical Exam-
iners . . .
(a) Proposed Regulation Regard-
ing Dispensing Medication
(N.J.A.C. 13:35-6.6) . . . Received
Mr. Maressa’s comment that the
regulation was good from a risk pre-
vention perspective. Also heard com-
ments from Dr. Riggs, acting presi-
dent of the State Board of Medical
Examiners, that the rule applies to
medications purchased by physi-
cians in bulk and dispensed directly
to patients. The proposed amend-
ment requires that such medi-
cations be labeled with name of the
dispenser, name of the patient, date
when medication is dispensed, a de-
scription of the drug, and adequate
instructions to the patient.
(b) Physical Examinations by
Nurses . . . Received information
from Dr. Riggs that the State Board
of Nursing's recent memorandum
instructing nursing schools to in-
clude in their curricula testicular,
vaginal, bimanual pelvic, and rectal
examinations was not acceptable; it
would be in violation of the Medical
Practice Act for a nursing physical
examination to be used to arrive at
a medical diagnosis and the Board
of Nursing must inform professional
schools and future licensees of the
SBME’s position.
(c) Corporate Practice of Medicine
. . . Received information from Dr.
Riggs on SBME’s recent ruling on
the corporate practice of medicine,
which prohibits a nonphysician
from hiring physicians to practice
medicine. The ruling does not apply
to hospitals and HMOs. When ques-
tioned if ruling applies to corpor-
ations formed by hospitals as non-
profit entities. Dr. Riggs said SBME
had not considered this aspect; sug-
gested Mr. Maressa request a ruling.
Directed the executive staff to
prepare a white paper on hospital
corporate structures, their forma-
tion, and purpose, for the unin-
formed.
(5) Hospital Medical Staff Section
. . . Voted to approve the establish-
ment of a Hospital Medical Staff Sec-
tion, to become an official Section of
the Medical Society of New Jersey’s
House of Delegates, which shall re-
main functional during the entire
administrative year and shall report
to the Board of Trustees.
Committee on Medical Defense and
Insurance . . . Considered all
aspects of the current Legal Services
Plan, heard Steven I. Kern, Esquire,
report on the activities of the plan
during 1983, and approved the fol-
lowing recommendation:
That the Legal Services Plan be con-
tinued in its present form, since it
provides high-quality legal services at a
modest expense to members of the So-
ciety.
Note: Dr. Riggs requested a post-
ponement of action on the above rec-
ommendation until April so that he
might respond in writing to Mr.
Kern’s report. Further consideration
will be given to this matter at the
April meeting. The Chairman of the
Committee on Medical Defense and
Insurance will be asked to attend the
April meeting for additional input.
March Meeting of State Board of
Medical Examiners . . . Received as
informative. Trustee Dr. Fullerton’s
report of the March 14, 1984, meet-
ing of the State Board of Medical
Examiners, containing the following
items on which Dr. Riggs com-
mented:
( 1 ) Termination of Pregnancy . . .
Changed period in which abortions
can be performed in a licensed and
approved facility in the state of New
Jersey to up to 18 weeks from last
menstrual period.
(2) Senate Bill 111 ... Opposed
bill requiring a physician personally
to present consent form for surgery
to patient for signature. SBME
urges MSNJ likewise to oppose this
legislation.
(3) Flex Examinations ... A total
of 256 individuals took these exam-
inations, of which 92 (36 percent)
passed, 164 (64 percent) failed.
Old Business . . .
Medicaid Personal Physician Plan
. . . Noted concern of William Silver-
man, M.D., of Atlantic County, rela-
tive to commitment made by chair-
man of the Committee on Medicaid
in letter of December 14, 1983, to
monitor all efforts of the Division of
/OL. 81— NUMBER 5— MAY 1984
423
Medical Assistance and Health Ser-
vices, and fact that the Committee
on Medicaid had not met since Octo-
ber. The Board’s only comment was
that the Committee would be meet-
ing on April 25, 1984.
New Business . . .
(1) DRG Hearing . . . Noted that
Congressman James J. Florio had
extended an invitation to Camden
County Medical Society to testify at
a hearing before the U.S. House of
Representatives’ Select Committee
on Aging’s Subcommittee on Health
and Long-Term Care on March 30 in
Blackwood. Noted the purpose of the
meeting is to assess New Jersey’s ex-
perience with the DRG reimburse-
ment system. Francis X. Keeley, M.D.,
of Camden County, and Alfred A.
Alessi, M.D., cochairman of the Ad
Hoe Committee on Presentation of
MSNJ’s DRG Position, will attend
the meeting.
(2) Hospital Medical Staff Regu-
lations . . . Considered fact that new
constitution and bylaws at a local
hospital were drafted by the hospi-
tal’s attorney without prior input
from the medical staff. Noted active
membership on the medical staff is
contingent upon physician’s use of
hospital facilities. Also, noted staff is
directed to consult with its attorney
to ascertain if MSNJ intervention is
necessary and MSNJ will contact
presidents of medical staffs, with
copy to county medical societies,
suggesting that each medical staff
engage legal counsel. Directed that
communication be sent to presi-
dents of medical staffs urging them
to elect a delegate to attend AMA
Hospital Medical Staff Section meet-
ings.
Note: This resulted from statements
by Dr. Kristeller, chairman of the
New Jersey Chapter, AMA Hospital
Medical Staff Section, on fact that
the AMA is developing a policy to
allow medical staffs to have sole
authority to select and remove its
own officers, to set standards for
medical staff patient care, and to es-
tablish and enforce criteria and
standards for medical staff member-
ship and clinical privileges. Medical
staff bylaws would incorporate these
principles, and the AMA’s JCAH
Commissioners would seek adop-
tion of these points in the JCAH Ac-
creditation Manual for Hospitals.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
UMDNJ’s new Cancer Research
and Treatment Center in Newark is
now open to treat patients with an
advanced radiation therapy ma-
chine. The Center is staffed and
equipped to handle all cancer pa-
tients who require radiation ther-
apy. Previously, University Hospital
patients needing such treatment
had to be referred to other institu-
tions, often to centers outside of New
Jersey. Besides the treatment itself,
the Center is capable of doing its
own treatment planning and simu-
lation.
In coming months, the highly
specialized technique of surgically
exposing tumors for direct radiation
will be available for treating pa-
tients. Intraoperative radiation ther-
apy, offered at few other places in the
United States, enables massive
doses of radiation to be applied
directly to exposed tumor sites,
without affecting skin, muscle, and
other anatomy parts at risk in ex-
ternal radiation.
Two new key members of the
UMDNJ-New Jersey Medical School
faculty will play major roles at the
Center: Stephen M. Stowe, M.D.,
chairman of radiation therapy,
comes to UMDNJ from Children’s
Hospital of Los Angeles, where he
was director of the Division of Radi-
ation Oncology, and the University
of Southern California School of
Medicine, where he was an assistant
professor in the departments of
radiology and pediatrics; and Robert
L. DeJager, M.D., director of medical
oncology, was previously a member
of the Cornell University medical fac-
ulty and thereafter director of
clinical pharmacology at the In-
stitute Jules Bordet, cancer center of
the Free University of Brussels.
The Cancer Research and Treat-
ment Center, which is open for treat-
ment and consultation 8 A.M. to 4:30
p.m., Monday through Friday, uses an
SL 75-20 linear accelerator, which
dispenses radiation with extreme
precision through a beam control
system that minimizes damage to
healthy surrounding tissue and or-
gans. The accelerator processes and
displays treatment regimens on a
console incorporating a micropro-
cessor and a video display unit.
The machine has four distinct
radiation sources:
• An 8 million volt x-ray beam ad-
vantageous for treating deep-rooted
cancers such as tumors of the pan-
creas or uterus.
• An 18 million volt x-ray beam
useful for treatment that is particu-
larly difficult because of the tumor’s
location and size, such as cancer of
the cervix.
• Electron particle beams which,
because they are less penetrating,
are beneficial in treating skin and
close-to-the-surface cancers and
tumors around the head and neck,
where the brain and spinal cord
must be safeguarded.
• A special high-output beam in-
tended principally for research but i
also useful for sterilizing blood and
other products.
Information about the patient’s
cancer is programmed through the
accelerator unit’s treatment plan-
ning center to determine the best
form of treatment. The validity of the
computer’s approach then is tested
through the simulator, a facsimile of
the linear accelerator.
More than 10 years in the plan-
ning and construction, the Cancer
Research and Treatment Center, ad-
jacent to University Hospital and the j
New Jersey Medical School on the
Newark campus, will provide a state-
wide resource and referral facility
specializing in the most difficult j
cancer cases and significantly will
benefit the broad cancer research ef-
forts already ongoing at the Univer-
sity. The Center offers new hope to
the people of a state which has the
fourth highest cancer death rate in
the nation.
AMNJ Report
Paul J. Hirsch, M.D.
President
Plans are proceeding for the ;
Academy of Medicine’s Annual
Awards Dinner. It will be held at the
Chanticler in Short Hills; the date is
Wednesday, May 23, 1984. Fellows of
the Academy, friends, families, and
colleagues will join us to honor the
achievements of our Award recipi-
ents, and formally to install our new
officers.
As a special feature of the dinner
this year, the Academy of Medicine
has commissioned an original work
of art by noted artist, Richard
Kemble. This will depict the famous
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
L
424
rinceton Battlefield Tree. An orig-
lal signed and numbered copy will
e given to guests at the dinner.
As previously announced. Dr.
Ifred A. Alessi will receive the Ed-
ward J. Ill Award for leadership in
ledicine. Congressman James
ourter will receive the Citizen’s
ward for his multiple efforts on
ehalf of the health of the citizens of
ew Jersey. His particular interests
ave been liver transplants for chil-
ren, health care for the elderly,
ealth care for veterans, and re-
?areh and treatment for victims of
lzheimer’s disease.
New officers to be installed at the
inner are: Robert Rigolosi, M.D.,
resident; Dennis Filippone, M.D.,
resident-Elect; Arthur Krosnick,
I.D., First Vice-President; and
nthony Minnefor, M.D., Second
ice-President. Dr. Benjamin Rush
ill serve as Secretary, and Dr. E.
harles Eckstein will serve as
reasurer for the forthcoming year.
The Academy of Medicine spon-
)red or cosponsored several major
/mposia during April.
A symposium on “Management of
atients with Low Vision” was held
a Saturday, March 31, 1984, at
ind in cooperation with) Saint
amabas Medical Center.
The Ninth Annual New Jersey Or-
lopaedic Symposium was held on
riday and Saturday, April 6 and 7,
984. On Friday afternoon there was
conference on complications in or-
lopaedic surgery, chaired by four
jest professors. That evening a
inner was given at the Hyatt Regen-
i Hotel in New Brunswick, featur-
ig Earl Ubell, Health and Science
ditor of WCBS-TV news, as the
(ter-dinner speaker. His topic was
Dthical Questions Involving Or-
lopaedic Surgery and the Media"
he symposium on Saturday, April
, 1984, was held at Rutgers Medical
chool from 8:00 A.M. until 4:30 p.m.
:ixteen papers were presented.
A major symposium on “Current
erinatal Ultrasonography" was
eld at Newark Beth Israel Medical
lenter on Saturday, April 14, 1984.
his program presented an update
j>r physicians in current techniques
f perinatal ultrasonography.
On Wednesday, April 18, 1984, a
/mposium on “Substance Abuse
jnd Misuse: An Update” was held at
ie MSNJ headquarters building,
his program was cosponsored by
ie Academy of Medicine and the
OL. 81— NUMBER 5— MAY 1984
Medical Society of New Jersey.
Joseph Ruggles, our new As-
sociate Director for Continuing
Medical Education arrived at the
Academy in early April. We look for-
ward to his strong participation in
the process of continuing education
for physicians in New Jersey.
The 9th Annual Conference of the
Alliance for Continuing Medical
Education focused on the need for
organizations to help physicians in-
dividualize their educational pro-
grams, so as to be most pertinent to
their own practices. The following
were objectives: to agree upon a com-
mon definition of individualized
learning: to identify practical
methods of providing individualized
learning; to develop mechanisms by
which continuing medical educa-
tion (CME) providers may assist
physicians in planning their indi-
vidualized learning; to provide a
forum for discussion and exchange
of ideas among CME providers: and
to promote formation and support of
information networks among CME
provider colleagues.
This meeting provided a begin-
ning, to allow educators to become
comfortable with the concept of in-
dividualized tailoring of CME. The
keynote speaker pointed out that
the phrase “individual learning”
is redundant: all learning is done by
an individual. “Individualized learn-
ing” is little better; each individual
self-designs learning programs and
processes throughout life. The term
“individually tailored CME” was of-
fered as indicating the presence of a
standard process, focused on the
needs of the individual. These
semantic discussions served the
purpose of allowing the participants
to communicate with each other
about this concept.
Cost factors increasingly are im-
portant. Funding for hospital CME
programs is expected to diminish
under the federal DRG system.
These same factors may decrease
funds available to full-time phy-
sicians to attend educational pro-
grams which require travel. This will
reinforce the trend for education to
be closer to home.
To some extent, the concepts dis-
cussed require a transfer of re-
sponsibility for CME from the
educator to the learner. Providers
can help the physician to assess
educational needs, to identify educa-
tional activities, and to help plan
those activities. This will involve a
new process, one which will change
the relationship between the indi-
vidual physician and the educator,
and which is likely to enhance con-
tinuing education in medicine.
The participants agreed upon cer-
tain concepts, if not precise defi-
nitions. It is neither desirable nor
feasible for educational organiza-
tions to design an individualized
educational program for each phy-
sician. However, each physician nat-
urally designs an educational pro-
gram, by selecting what is read, what
meeting shall be attended, and what
new techniques shall be learned. Or-
ganizations can assist membership
by performing needs-assessment
surveys of various types, in order to
design programs which will meet
the needs of certain large and small
groups within the membership. “In-
dividualized CME” may include
counseling services provided by or-
ganizations, to help the individual
determine those programs and pro-
cesses which are most suitable to a
specific educational need.
Diagnostic Virology
Laboratory, 1983,
Saint Michael’s Medical
Center, Newark
Types and numbers of viruses
isolated from specimens from north-
ern New Jersey metropolitan area
are as follows:
DNA Viruses
Herpes simplex type 1 (oral
strain)* 63
Herpes simplex type 2 (genital
strain) 110
Varicella-zoster 2
Cytomegalovirus 18
Adenovirus (untyped) 3
Adenovirus 2** 4
Adenovirus 3 1
Adenovirus 5 1
Adenovirus 7 1
Adenovirus 16 3
RNA Viruses
Polio 2 2
Polio 3 4
Coxsackie A-9 3
Coxsackie B-l 7
Coxsackie B-4 2
Coxsackie B-5 5
Echo 5 1
Echo 9 1
425
^Monoclonal antibody determined.
**Andeno and entero final I.D. by
state laboratoiy at Trenton.
Clinical significance— As in all
diagnostic virology laboratories, the
most frequent viral isolate in 1983
was herpes simplex virus. The avail-
ability of good fluorescein-labeled
monoclonal antibody in 1983 made
strain identification easy. It can be
seen that the genital strain was the
most frequent isolate, about twice as
many as the oral strain.
Many of the Cytomegaloviruses
were isolated from AIDS victims, in
whom this is one of the most com-
mon viral infections. The adeno-
isolates mainly were from children
with respiratory syndromes. No in-
fluenza was isolated by our labora-
tory in 1983. The polio viruses rep-
resent probable vaccine strains from
children. In 1983, the most common
entero virus isolate was Coxsackie
B- 1 . The number of echo viruses was
low as compared to previous years
when there were large numbers of
Echo 9 and Echo 11.
Frank J. Michalski, Ph.D.
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ALCOHOLISM — George W. Miller Jr.,
M.D., 77 Grove St., Apt. 8, Montclair, NJ
07042. UMDNJ 1980. Available July
1984.
ANESTHESIOLOGY— RS. Saraiya, M.D.,
88-25A 1 53rd St., Apt. 4-F, Jamaica NY
11432. Baroda (India) 1978. Group or
partnership. Available August 1984.
CARDIOLOGY — Aubrey Orrin Lewis,
M.D., 200 Carman Ave., Apt. 21-F, East
Meadow, NY 1 1 554. SUNY-Syraeuse
1979. Also, general internal medicine.
Board certified (1M). Solo, partnership,
group, academia (cardiology). Available
July 1984.
FAMILY MEDICINE— Jaime F. Lara
M.D., 6045 Palisade Ave., West New
York, NJ 07093. Seville (Spain) 1979.
Board eligible. Partnership or institu-
tionally based. Available.
Laurence Levenberg, M.D., 63 Har-
rowgate Dr., Cherry Hill, NJ 08003.
SUNY-Upstate 1966. Group, partner-
ship, solo. Available July 1984.
GASTROENTEROLOGY— Prakash V.
Huded, M.D., 80-15 41 Ave., Apt. 606,
Elmhurst, NY 1 1373. Kamatak (India)
1970. Board certified. Solo, group, part-
nership. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, internal medicine. Part-
nership, group, full-time hospital.
Available July 1984.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia, MO 6520 1 . National Taiwan
University 1977. Also, internal medi-
cine. Board certified. Available July
1984.
INTERNAL MEDICINE— Nicholas
Bertini, M.D., 663 Hudson Ave., Albany,
NY 12203. SUNY-Buffalo 1980. Board
eligible. Group, partnership, solo. Avail-
able June 1984.
Palamadai S. Duraiswami, M.D., 64-A
Oneida Ave., Centereach, NY 11720.
Stanley Medical College (India) 1976.
Board eligible. Available.
Z.UA Farooqui, M.D., Plaza Pro-
fessional Bldg., Bayshore Rd. and
Greenwood Ave., Box 238, Villas, NJ
08251. Aurangabad Medical College
(India) 1972. Board eligible. Group or
partnership. Available.
Elliott Friedman, M.D., 25 Penny La.,
Baltimore, MD 21209. SUNY-Syracuse
1978. Subspecialty, endocrinology.
Board certified (IM); board eligible (M).
Group or partnership (both special-
ties). Available July 1984.
Lee W. Hoffer, M.D., 1017 E. 80th St.,
Brooklyn, NY 11236. Rome (Italy) 1980.
Solo, partnership, group. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, gastroenterology. Part-
nership, group, full-time hospital.
Available July 1984.
Quang T. Nguyen, M.D., 15 W.
Englewood Ave., Bergenfield, NJ 07621.
Saigon (South Vietnam) 1967.
Subspecialty, nephrology. Boar
eligible. Any type practice. Availabl
July 1984.
Andrew L. Saporito, Jr., M.D., 2
Grandview Ave., West Orange, N
07052. Guadalajara (Mexico) 197(
Group or partnership. Available.
Richard B. Schwarz, M.D., 8300 D<
Longpre Ave., Apt. 204, Los Angeles, C,
90069. NYU 1979. Subspecialh
nephrology. Board certified. Grou]
HMO, hospital. Available July 1984.
Gopal Shah, M.D., 100 Caton Ave., Api
2-G, Brooklyn, NY 1 1218. M.R Medic;
College (India) 1976. Board eligibli
Group. Available July 1984.
Mark F. Tsai, M.D., 1715 Stanford Dr
Columbia, MO 65201. National Taiwai
University 1977. Also, gastroentei
ology. Board certified. Available Jul
1984.
M.S. Vafa, M.D., 10378 Gosport, Apt. £
St. Louis, MO 63146. Ferdowsi 197£
Subspecialty, radiology. Boari
certified. Group or partnership. Avail
able.
Steven Wolinsky, M.D., 1404 E. 15 St
Brooklyn, NY 1 i230. Case Western Re
serve 1980. Group or partnership
Available July 1984.
NEPHROLOGY — Quang T. Nguyen, M.D
15 W. Englewood Ave., Bergenfield, Nl
07621. Saigon (South Vietnam) 1967
Also, internal medicine. Board eligible
Any type practice. Available July 1984
Richard B. Schwarz, M.D., 8300 De
Longpre Ave., Apt. 204, Los Angeles, Cl
90069. NYU 1979. Also, internal medi
cine. Board certified (IM). Group, HMO
hospital. Available July 1984.
OBSTETRICS/GYNECOLOGY— Balwan
K. Chhatwal, M.D., 6416 Fairfield Ave.
Berwyn, IL 60402. Delhi (India) 1975
Group, partnership, solo. Available JuL
1984.
Sheela Choubey, M.D., 1 Zirkel Ave.
Piscataway, NJ 08854. Poona (India
1977. Board eligible. Group or partner
ship. Available July 1984.
Atul S. Sheth, M.D., 2951 S. King Dr.
Chicago, IL 60616. Specializing in in
fertility, reproductive endocrinology
Board eligible. Partnership, single oi.
multiple-group practice, academia;
Available.
Ernest A. Topran, M.D., 3523 Dew-;
berry-Southem Oaks, Shreveport, LA
71118. Louisiana State 1980. Group or j
partnership. Available July 1984.
PEDIATRICS— Dorothea H. Gross, M.D.,:
264 Boonton Turnpike, Lincoln Park,
NJ 07035. Geneva (Switzerland) 1950.
Clinic, group, emergency room, hospi-
tal, pharmaceutical research (salaried).
Available.
Kusumam Sidharthan, M.D., 222
Yorkshire Ct„ Old Bridge, NJ 08857.
Calicut Medical College (India) 1976.
Board eligible. Available July 1984.
PSYCHIATRY— Eric M. Levin, M.D., 43
West 8th St., Media, PA 19063. La Fac-
ulty Libre de Medicine (Spain) 1980.
Are You Moving?
If so, please send us your change of address, at least six
weeks before you move.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
426
Board eligible. Group, institutionally
based, CMH outpatient. Available July
1984.
ULMONARY DISEASES— James
Kohan, M.D., 19 Highmanor Dr., Hen-
rietta. NY 14467. Virginia 1979. Also,
general internal medicine. Board
certified (IM). Group, partnership, solo,
institutional. Available July 1984.
Dinesh Talati, M.D., 66-02 Grand Cen-
tral Pkwy., Forest Hills, NY 1 1375. B.J.
Medical College (India) 1974. Board
eligible. Solo, group, partnership. Avail-
able July 1984.
ADIOLOGY/ NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon
St., Apt. 3B, Brookline, MA 02146. Bos-
ton 1976. Board certified. Group or
partnership. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond
Brook Rd., Chestnut Hill, MA 02167.
Medical College of Pennsylvania 1980.
Board eligible. Group, HMO, academia.
Available.
Subhash S. Pujara, M.D., Box 39 IB, Rt.
3, Andalusia, AL 36420. B.J. Medical
College (India) 1969. Board certified
(radiology); board eligible (nuclear
medicine). Group, partnership, solo.
Available.
M.S. Vafa M.D., 10378 Gosport, Apt. 9,
St. Louis, MO 63146. Ferdowsi 1973.
Also, internal medicine. Board
certified. Group or partnership. Avail-
able.
IURGERY, GENERAL— Sara A Case,
M.D., 284 Quinby Rd., Rochester, NY
14623. Virginia 1975. Board eligible.
Group — general surgery in moderate-
sized city. Available August 1984.
Ruben J. Delgado, M.D., 7514 Oriental
Tr„ San Antonio, TX 78244. Puerto
Rico 1976. Also, vascular surgery.
Board certified. Single or multi-
specialty' group or solo. Available
August 1984.
F. Andrew Morfesis, M.D., 7545 Rogers
Ave., Upper Darby, PA 19082. Penn
State (Hershey) 1979. Board eligible.
Available July 1984.
James M. Stem, M.D., 600 Vista Court,
Waynesboro, PA 17268. Jefferson
1958. Board certified. Solo, with free-
dom to practice in broad spectrum of
surgery, including vascular and frac-
tures. Available June 1984.
SURGERY, ORTHOPEDIC — S.N.
Saraiya M.D., 88-125A 153rd St., Apt.
4-F, Jamaica NY 1 1432. Baroda (India)
1974. Solo. Available August 1984.
SURGERY, VASCULAR— Ruben J.
Delgado, M.D., 7514 Oriental Tr„ San
Antonio, TX 78244. Puerto Rico 1976.
Also, general surgery. Board certified
(GS). Single or multispecialty group or
solo. Available August 1984.
UROLOGY— Kiritkumar M. Pandya,
M.D., 950 49th St., Apt. 9-A, Brooklyn,
NY 11219. Baroda (India) 1970. Board
eligible. Group, partnership, solo. Avail-
able.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains.
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
( BRoMJfc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 JM®
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ANNUAL AWARDS DINNER
of
THE ACADEMY OF MEDICINE
OF NEW JERSEY
Wednesday, May 23, 1984
6:00 P.M.
at
THE CHANTICLER
Short Hills, New Jersey
1984 AWARD RECIPIENTS
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
May 25-27, 1984 and again the weekend of July 6-8, 1984 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
office journal, Acupuncture & Electro-Therap. Res., Int.J. (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Re-
search Foundation and the Neuroscience Dept, of Long Island
College Hospital, Pharmacology Dept, of The Chicago Medical
School. Also eligible for AMA/CME credit. For information, con-
tract Y. Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC
10032. Tel: (212) 781-6262 or (212) WA8-0658, or Saul Heller,
M.D., Tel: (212) 838-7514.
EDWARD J. ILL AWARD
ALFRED A. ALESSI, M.D.
CITIZENS AWARD
CONGRESSMAN JAMES COURTER
(R~12th District)
SPECIAL RECOGNITION AWARD
SYLVAN E. MOOLTEN, M.D.
For further information, please contact:
EXECUTIVE OFFICES
The Academy of Medicine of New Jerst^
® ||| 5 Two Princess Road
v” ® Lawrenceville, NJ 08648
of lSL‘£;Isey (609) 896-1717
NEW JERSEY SOCIETY OF PATHOLOGISTS
June 16, 1984
ANNUAL SPRING MEETING
SATURDAY, MAY 19, 1984
4th Annual Advances
AT
UHUDNJ-RUTGERS MEDICAL SCHOOL. PSSCATAWAY. NJ
in Gastroenterology
8:00 2:00 P.M.
ON
“PRACTICAL APPLICATION OF LYMPHOCYTE
Golden Nugget Hotel
TYPING FOR PATHOLOGISTS”
Atlantic City, New Jersey
Program Chairman:
r ■
Stebbins B. Chandor, M.D.
The program is designed for pathologists to
Sponsored by the Gastrointestinal Section
become familiar with recent advances in clinically
of the Hospital of the
relevant immunologic techniques which are of im-
University of Pennsylvania
portance in the practice of pathology.
and
The objectives are to demonstrate ways in
the Continuing Medical Education
which newly developed immunological tech-
Department of the
niques may be utilized in the diagnosis of a variety
Underwood Memorial Hospital
of diseases with special emphasis on hematologic
malignancies.
Woodbury, New Jersey
For further information contact:
Category 1 credit offered
Cathy Gillmer
Executive Secretary
New Jersey Society of Pathologists
Two Princess Road
Information: Registration Supervisor, SLACK In-
Lawrenceville, New Jersey 08648
corporated, 6900 Grove Road, Thorofare,
Phone: (609) 896-1717
New Jersey 08086, 609-848-1000
428
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
ME Calendar
lis list is compiled through the coop-
ation of the Committee on Medical
ilucation of the Medical Society of New
:rsey, the Academy of Medicine of New
:rsey, the New Jersey Chapter of the
nerican Academy of Family Phy-
cians, and the Office of Continuing
edical Education of the UMDNJ. For
formation on accreditation, please
•ntact the sponsoring organization (s),
dicated by italics— last line of each
;m.
VESTHESIOLOGY
jme
1 Anesthesia Lectures
L 7-8 AM. — NJ Medical School,
3 Newark
5 (UMDNJ)
) Anesthesia Lectures
i2 4-5 P.M. — NJ Medical School,
3 Newark
5 (UMDNJ)
3 Anesthesia Grand Rounds
|3 4-5 P.M.— University Hospital,
p Newark
7 (UMDNJ)
ARDIOLOGY
one
3 Preventive Cardiology Seminar
0 1 2 noon- 1 P.M.— NJ Medical School,
Newark
(UMDNJ)
6 Vascular Conference
3 4-5 P.M. — NJ Medical School,
0 Newark
7 (UMDNJ)
6 Cardiac Arrhythmias
1 -2:30 P.M. — Christ Hospital, Jersey
City
(Christ Hospital and AMNJ)
MEDICINE
June
1 Urology Grand Rounds
8 3-5 P.M. — NJ Medical School,
15 Newark
22 (UMDNJ)
29
1 Renal Conferences in Nephrology
15 4-5 P.M. — University Hospital,
Newark
(Nephrology Society of NJ and
Nephrology Section AMNJ)
1 Grand Rounds in Rehabilitation
1 :30-2:30 P.M. — Rotates between
University Hospital, Newark,
Kessler Institute, West Orange, and
Children's Specialized Hospital,
Westfield
(UMDNJ)
1 Dept, of Medicine Grand Rounds
8 1 1:30 AM.-l P.M.— NJ Medical
15 School, Newark
22 (UMDNJ)
29
6 Endocrine Conferences
13 3:30-5 P.M. — Rotates between
20 Newark Beth Israel Medical
27 Center, University Hospital,
Newark, and United Hospitals
Medical Ctr., Newark, and VA
Medical Center, E. Orange
(Endocrinology Section AMNJ)
6 Rehabilitation Medicine
13 4:15-5:15 P.M. — Kessler Institute,
20 West Orange
27 (UMDNJ)
6 Medical Grand Rounds
1 1 :30 AM. — VA Medical Ctr., East
Orange
(Endocrinology Section AMNJ)
6 Gastrointestinal Bleeding
1:30-2:30 P.M. —Essex County
Hospital, Cedar Grove
(Essex County Hospital and AMNJ)
6 Therapeutic Controversies in GI
Diseases
1:30-5 P.M. — Saint Barnabas
Medical Ctr., Livingston
(NJ Gastroenterological Society
and AMNJ)
6 Common Allergy Problems
20 Inflammatory Bowel Disease
1:30-2:30 P.M. — Rutgers
Community Health Plan, 57 U.S.
Hwy. 1, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
7 Digestive Disease I
14 8-9 AM. — NJ Medical School,
21 Newark
28 (UMDNJ)
7 Digestive Diseases n
14 9-10A.M. — NJ Medical School,
21 Newark
28 (UMDNJ)
7 Allergy, Immunology Lecture
14 1 1 A M - 12 noon — Children’s
21 Hospital, Newark
28 (UMDNJ)
7 Management of Short Stature
9 AM. — Freehold Area Hospital
(AMNJ)
7 Medical Grand Rounds
9:30 A.M. — Newark Beth Israel
Medical Center
(Endocrinology Section AMNJ)
7 Irritable Bowel Syndrome
1 1 AM.— St. Joseph’s Hospital and
Medical Center, Paterson
(St Joseph's Hospital and Medical
Center and AMNJ)
8 Medical Grand Rounds
1 1:30 A.M. — UMDNJ-University
Hospital, Newark
(Endocrinology Section AMNJ)
1 2 Fluid and Electrolyte Imbalance
1 1 AM.- 12 noon — Greystone Park
Psychiatric Hospital
(Greystone Park Psychiatric
Hospital and AMNJ)
14 Rheumatology Update
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 9 Continuous Arteriovenous
Hemofiltration
4- 5 P.M. — Academic Health Science
Center, New Brunswick
(UMDNJ and AMNJ)
19 IVP Conference
5- 7 P.M. — East Orange VA Hospital
(UMDNJ)
20 Interhospital Rheumatology
Rounds
4:30-6 P.M. — University Hospital,
Newark
(UMDNJ)
20 Pathogenesis, Diagnosis, and
Management of Type II Diabetes
1-2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
20 Dermatological Conference
6- 9 P.M. — Rutgers Community
Health Plan, 57 U.S. Hwy. 1, New
Brunswick
(UMDNJ and AMNJ)
20 Cancer of the Colon
27 Diabetes Mellitus
10:30-12 noon — St. Mary's
Hospital, Passaic
(St Mary's Hospital and AMNJ)
20 Gastroesophageal Reflux
27 Peptic Ulcer Disease
8- 9 AM. — Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
20 Chronic Liver Disease
9- 10 AM.— Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
NEUROLOGY/PSYCHIATRY
June
1 Psychiatric Lecture Series
8 1:30-5 P.M. — Trenton Psychiatric
15 Hospital
(Trenton Psychiatric Hospital and
AMNJ)
4 Depression in a Patient
8: 1 5- 1 0:30 P.M. — 1 046 So. Orange
Ave., Short Hills
(Essex Psychiatric Seminar and
AMNJ)
4 Psychotherapies
1 1 Psychotherapies
25 Behavior Modification
1 -3 P.M. — Ancora Psychiatric
9L. 81— NUMBER 5— MAY 1984
429
BRAIN TUMOR SYMPOSIUM:
ADVANCES IN DIAGNOSIS
AND MANAGEMENT
OF CEREBRAL GLIOMAS
Saturday, June 9, 1984, 8:30 A.M.— 12 Noon
Alumni Hall, 2nd Floor, New College Building
Hahnemann University, 15th and Vine Streets
Philadelphia, Pennsylvania
Sponsored by
THE HAHNEMANN BRAIN TUMOR PROGRAM
An interdisciplinary treatment and research
program of the Hahnemann Departments of
Diagnostic Radiology, Hematology/Oncology,
Neurology, Neurosurgery, and Radiation Oncology
in collaboration with
The Wistar Institute for Anatomy and Biology
HAHNEMANN UNIVERSITY
SCHOOL OF MEDICINE
PHILADELPHIA, PENNSYLVANIA
Symposium Chairman:
Perry Black, M.D.
Department of Neurosurgery
Hahnemann University Hospital
(215) 448-8072
AMA approved: Category I Fee: $20.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
I
HU
430
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
> Grand Rounds in Psychiatry
10:30 AM.- 12 noon— NJ Medical
School, Newark
(UMDNJ)
i Psychoneuroimmunology
9:30 A.M.-5 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
i Group Therapy
2-3 P.M. — Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
i Management of Pain
8- 9 A.M. — Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
) Spinal Opiate Therapy in Chronic
Cancer Pain
9- 10 AM — Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
Calcium Channel Blockers in the
Brain
Adolescents and Families with
Drug and Alcohol Problems
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
(Somerset Medical Center and
AMNJ)
July
2 Behavior Modification
9 1-3 P.M. —Ancora Psychiatric
16 Hospital, Hammonton
23 (Ancora Psychiatric Hospital and
AMNJ)
5 Basic Neurological Principles for
Neuropsychiatrists
1 2 Significance of Headache in
Clinical Psychiatry
19 Treating the Remarried, Those
Living Together, and Their
Families
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 9 Family and Couple Therapy
12 noon-4:30 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
PATHOLOGY
June
1 3 Pathology Grand Rounds
10:30-12 noon — St. Mary’s
Hospital, Passaic
(St Mary's Hospital and AMNJ)
14 Pathology Seminar
1 2 noon- 1 P.M.— NJ Medical School,
Newark
(UMDNJ)
i Problem Behaviors in
Adolescence
8 A.M.-3:30 P.M .— NJ Medical
School, Newark
(UMDNJ, NJ Council of Child and
Adolescent Psychiatry, and AMNJ)
i Problem Behaviors in
Adolescence
8 AM. -3:30 P.M. — NJ Medical
School, Newark
(UMDNJ, NJ Council of Child and
Adolescent Psychiatry, and AMNJ)
i Patient Compliance: Treatment
Issues
1-2:30 AM. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
l Principles of Child Psychotherapy
8:30- 10:30 P.M — 301 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
> Lecture in Psychiatry
10:30 AM.- 12 noon — NJ Medical
School, Newark
(UMDNJ)
• Psychiatry Lecture
1-2:30 P.M.— Essex County Hospital
Center, Cedar Grove
(UMDNJ)
Update of Clinical Psychiatry
12 noon-4:30 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
The Many Faces of Clinical
Depression
5-6:30 P.M. — Somerset Medical
Center, Somerville
PEDIATRICS
June
1 Advances in Pediatrics
8 9:30- 1 0:30 AM.— NJ Medical
School,
15 Newark
22 (UMDNJ)
29
8 AIDS in Children
8-9:30 AM. — Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
9 Problem Behaviors in
Adolescence
8 AM. -3:30 P.M.— NJ Medical
School, Newark
(UMDNJ, NJ Council of Child and
Adolescent Psychiatry, and AMNJ)
1 8 Practical Aspects of Pediatric
Toxicology
12 noon-1 P.M. — The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
RADIOLOGY
June
6 Radiology Grand Rounds
20 2-4 P.M. — University Hospital,
Newark
(UMDNJ)
1 3 Diagnosis of Biliary Tract Disease
8-9 A.M. — Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
27 CT Conference
4-6 P.M. — University Hospital,
Newark
(UMDNJ)
July
2 Basic, Advanced, and Real-Time,
3 Cross-Sectional Sector Scanning
4 9 A.M. -5 P.M.— Sands Hotel, Atlantic
5 City
6 (The National Foundation for Non-
invasive Scanning and AMNJ)
SURGERY
June
2 Surgical Morbidity and Mortality
9 Conference
16 8:30-10 A.M. — NJ Medical School,
23 Newark
30 (UMNDJ)
4 Surgical Grand Rounds /Lecture
1 1 Series
18 4:30-5:30 P.M. — NJ Medical School,
25 Newark
(UMDNJ)
6 Surgical Departmental
13 Conference
20 8:30-10 AM. — Rutgers Medical
School, Medical Education Bldg.,
New Brunswick
(UMDNJ and AMNJ)
SURGICAL SPECIALTIES
June
1 Cancer Research Colloquium
8 12 noon- 1 P.M. — University
15 Hospital, Newark
22 (UMDNJ)
29
2 Surgical Treatment of
Cardiothoracic Diseases
1 0- 1 1 :30 AM. — NJ Medical School,
Newark
(UMDNJ)
4 Tumor Conference
11 8-9A.M. — University Hospital,
18 Newark
25 (UMDNJ)
7 Vascular Surgical Rounds
14 4-5 P.M. — Rutgers Medical School,
21 Medical Education Bldg., New
28 Brunswick
(UMDNJ and AMNJ)
13 Ischemic Diseases of the Bowel
27 Surgical Treatment of Peptic Ulcer
Disease
9- 10 AM. — Elizabeth General
Medical Center
(Elizabeth General Medical Center
and AMNJ)
1 9 Surgical Treatment of Morbid
Obesity
12 noon— St. Mary’s Hospital,
Orange
(AMNJ)
20 Eye Institute Grand Rounds
7-9 P.M. — United Hospital Annex
Bldg.
(UMDNJ)
2 1 Neurosurgery Lecture
4-5 P.M. — University Hospital,
Newark
(UMDNJ)
9L. 81— NUMBER 5— MAY 1984
431
More people have survived cancer than
now live in the City of Los Angeles.
We are winning.
Please support the
V AMERICAN CANCER SOCIETY
7
432
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE:
BOOK REVIEWS
Clinical Nuclear Medicine;
Computerizing Your
Medical Office; Current
Therapy in Obstetrics and
Gynecology II; Illustrated
Computer Tomography;
Nuclear Magnetic
Resonance; Pacemaker
Therapy
i'
'
i
C linical Nuclear Medicine
f.JV. Maisey, K.E. Britton, D.L. Gil-
lay (eds). Philadephia, PA, W.B.
launders, 1983. Pp. 525. II-
xstrated. ($60)
This condensed work, to which
le contributors are physicians
‘om the British Commonwealth as
fell as from the United States,
dopts a different approach from
ther texts. Its emphasis rests less
n interpretative skills and more on
•linical correlation and differential
iagnosis. The authors review a
'road spectrum of topics, ranging
rom the organ systems, e.g. cardiac,
espiratoiy, and neurological, to sub-
lets of special consideration, such
s pediatric nuclear medicine.
The chapter on respiratory dis-
ase, for example, reviews basic sci-
nce and then moves on to the the-
ory behind ventilation/perfusion
canning in embolic disease; the dis-
ussion includes a related section
n deep-vein thrombosis. Appli-
ations of nuclear medicine in
•ronchiogenic carcinoma are dis-
missed as are other diseases. A short
lescription of the technique of ad
jainistration and control standards
p included.
I This text will not enable one to
interpret scans. However, it is a com-
panion text which will augment the
physician’s understanding of the
nuclear images.
Neil B. Homer, M.D.
Computerizing Your
Medical Office: A Guide
for Physicians and Their
Staff
Dot Sellars. Oradell, NJ, Medical
Economics Books, 1983. Pp. 228.
($11.50)
Dot Sellars’s book is one of the
"how-to-automate” books. Such
books recently have appeared for
novice purchasers of small business
computer systems.
Sellars, a medical office adminis-
trator, does a good job in addressing
specific needs for physician office
automation. I give the book high
grades for both readability and prac-
ticality. The reader must be aware
that the book addresses mini-
computer-based medical billing sys-
tems, not home computers with
medical billing software.
A skillful layout makes the book
easy to read and follow because the
author writes in the terminology of
the medical office; the reader will not
have to consistently refer to the
glossary. The book is divided into
three major sections: Do you need a
computer? How to get the right com-
puter for your office? Making the
computer do everything you want?
Without a doubt these are the basic
questions which potential
purchasers want answered and
Sellars’s answers are practical.
Use of specific guidelines makes
the answers both practical and re-
assuring for the novice. For example,
Sellars presents an itemized guide-
line that allows the novice to reflect
on the office’s need for computer
support. Another practical guideline
is the steps to follow in shopping for
a computer. I also strongly support
the suggestions on employee in-
volvement in the computer selection
process. 1 am certain that a novice
purchaser will benefit from the
hand-holding these guidelines
provide.
For anyone starting a first-time
computer effort I recommend
Sellars’s book. Following her rec-
ommendations will ensure good
value for the money invested.
James W. Allen, M.D.
Current Therapy in
Obstetrics and
Gynecology II
Edward J. Quilligan, M.D. Phila-
delphia, PA, W.B. Saunders Com-
pany, 1983. Pp. 320. Illustrated.
($32.50)
The second edition of this popular
text has enlisted a new group of
authors to give the reader a spec-
trum of opinions about a given
topic. The chapters cover the fields
of obstetrics and gynecology and in-
clude such general medical and
surgical problems as hyperalimenta-
tion and atelectasis. The pathogen-
esis and treatment of each condition
under discussion briefly is
elucidated and often contains valu-
able insights and treatment sugges-
tions that reflect the experience and
expertise of the contributor.
Some shortcomings must be men-
tioned; A chart on antepartum fetal
heart rate monitoring recommends
a tracing be performed every two
weeks, when what is meant is twice
a week. The same figure suggests a
tracing every two to three weeks if
repetitive variable decelerations
occur. Most practitioners would em-
ploy weekly or semi-weekly testing.
There is some ambiguity in the
chapter on female sterilization when
in one paragraph coagulation of the
Fallopian tube at a distance of 1 cm
from the cornual insertion is rec-
ommended, while coagulation at
least 3 to 4 cm from the cornua is
suggested two pages later.
Overlapping of topics always is a
problem in any text with multiple
contributors. That a book with 120
contributors has such little dupli-
cation is a tribute to the skill of the
editor. The text is weighted toward
obstetrics, reflecting the advances in
that field. The book may be rec-
ommended for the resident or at-
tending physician who desires a
brief updating of a particular prob-
lem. It would make a great present
for a graduating resident.
Gerard F. Hansen, M.D.
Illustrated Computer
Tomography: A Practical
Guide to CT
Interpretations
Shinji Takahashi (ed). New York,
NY, Springer-Verlag, 1983. Pp.
306. Illustrated. ($83)
T>L. 81— NUMBER 5— MAY 1984
433
This review monograph is divided
into four sections: a concise techni-
cal review, a short atlas, representa-
tive clinical vignettes, and a dis-
cussion on application in radio-
therapy.
The technical summary is one of
the more concise. The atlas is com-
posed of well-illustrated drawings;
however, the corresponding CT im-
ages are of a poorer quality. The sec-
tion entitled, “Computed Tomo-
graphy of Disease,” has representa-
tive case studies which are exam-
ined in a very systematic manner
conducive to a good comprehensive
understanding of each case. The
book’s final chapter is devoted to the
application of computed tomogra-
phy in radiotherapy and attempts to
touch base with the important
aspects.
This is a short book for what it
attempts. More space should have
been devoted to the case studies and
less to the technical aspects. It is
recommended for the nonradiologist
who wishes insight into the inter-
pretative process of computer to-
mography.
Neil B. Homer, M.D.
Nuclear Magnetic
Resonance (NMR)
Imaging .
C. Leon Partain, A . Everette
James, F. David Rollo, Ronald R.
Price. Philadelphia, PA, W.B.
Saunders Company, 1983. Pp.
592. ($75)
With the recent interest in nuclear
magnetic resonance (NMR) imaging
has come a multitude of texts such
as the one edited by these re-
searchers at Vanderbilt University. It
stands in the middle between books
that rely on higher mathematics and
the basic introductory texts and
uses clear language.
The goal of this book is to touch
base with almost all areas of NMR
without complicated equations.
Selected topics include topical NMR
analysis and superconducting
magnetics. Included are results from
clinical research sites, e.g., Massa-
chusetts General Hospital. These are
of interest, but clearly are dated; this
section is the only weak point of the
book.
This work is considered to be one
of the better introductory texts and
is geared for those with some higher
mathematics. It deserves a place on
the shelf of physicians with a
serious interest in NMR imaging.
Neil B. Homer, M.D.
Pacemaker Therapy
Leonard S. Dreifus, M.D., (ed).
Philadelphia, PA, F.A. Davis Co.,
1983. Pp. 287. Illustrated. ($45)
This superb book is remarkably
up to date for a medical text. Un-
fortunately, its audience appeal will
be very limited because of many
highly technical contributions that
will unnerve even the most sophisti-
cated pacemaker maven. For exam-
ple, how many of our readers are
aware that today’s pacemakers have
multiprogrammable antitachycar-
dia features and telemetry and that
they can store patient information
and act as Holter monitors? Some
modem pacemakers are so in-
telligent that they can be “interro-
gated” only by computers!
Like most other multiauthored
texts, this one suffers from the over-
lap-repetition syndrome as well as
considerable unevenness in the fac-
tual display. Some chapters, such as
those devoted to the radiology r
pacemakers and the ECG analysis’:
pacemaker function, offer a
enormous amount of informathi
concisely, while others disturbing
are skimpy or overtechnical. An c
ample of the latter is, “Availah
T^pes of Pacemakers,” where evi
the authors conclude that keepi |
track of all the options on modei
pacemakers is as difficult as listi |
those available on a “modem luxi '
sedan.” Similar high-tech chaptt;
include “Pacemaker Implantatioi’
“Programmable Pacemakers," a I
“Pacing Leads.”
Steiner and Tegtmeyer present i
veiy valuable treatise on the radj
logic aspects of normal and e
normal pacemaker function. The f
ures, mostly plain films, are supei,
and the appendix of radiopaq
identification codes is a must 1’
every active pacemakemik.
Barold et al. offer a huge and d
ficult discussion on the EC
analysis of pacemaker functic
This cannot be handled in a p<
functoiy manner, for terms li
pseudofailure, pseudocapture, f
sion, pseudofusion, and pseuq*
pseudofusion will perplex even t
master electroeardiographer.
Contributions by Wellens et
and by Berkovits et al. deal with t
relatively new role of pacing in tj
treatment of the tachycardias. The
chapters are readable and pithy.
While some of the authors prese
pot-boiling rehashes, others, such
Mirowski’s, “Automatic Implantat
Defibrillator,” and Berkovits’s “F
ture Generation Pacemakers,” pre
ent exciting, new ideas.
Despite some shortcomings, tf
multiauthored text is clearly “stall
of the art.”
Edwin L. Rothfeld, M.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
434
BITUARIES
Drs. Azzara;
3emstein; Block;
farmer; Greenfield;
iermann; Kubes;
detzer; Nobile; and
itutchin
:. Emanuel S. Azzara
Vorcl has been received of the
ith of Emanuel S. Azzara, M.D., a
mber of our Mercer County com-
aent. Bom in 1896, Dr. Azzara
ned his medical degree at Tulane
iversity School of Medicine, Lou-
|ma, in 1924. A family practi-
ner, Dr. Azzara was affiliated with
nterdon Medical Center. He was
nember of the American Medical
sociation.
\ Ellen H. Bernstein
d the untimely age of 46, Ellen H.
mstein, M.D., died on Febmary
i 1984. An ophthalmologist. Dr.
mstein had a private practice in
zabeth for 13 years. Dr. Bernstein
eived her medical degree from
v York University School of Medi-
cine in 1963. A member of our Union
County component, Dr. Bernstein
was a Diplomate of the American
Board of Ophthalmology and a mem-
ber of the American Medical As-
sociation. During her career, Dr.
Bernstein was affiliated with two
Elizabeth hospitals: General Hospi-
tal and St. Elizabeth.
Dr. Paul J. Block
Paul J. Block, M.D., a member of
our Monmouth County component,
died on Febmary 7, 1984. Bom in
1938, Dr. Block earned his medical
degree from New York University
School of Medicine in 1964. A
cardiologist. Dr. Block was affiliated
with Monmouth Medical Center,
Long Branch, Freehold Area Hospi-
tal, and Bayshore Hospital, Holmdel.
A Diplomate of the American Board
of Internal Medicine, Dr. Block was
a Fellow of the American College of
Cardiology.
Dr. Walter D. Farmer
At the grand age of 84. Walter
David Farmer, M.D., died on Febm-
ary 7, 1984. He received his medical
degree from McGill University, Can-
ada, in 1926. Dr. Farmer was a fam-
ily practitioner affiliated with
Mercer Medical Center, Trenton. He
was a member of our Mercer County
component and of the American
Medical Association, and a Fellow of
the American Academy of Family
Practice. In 1976, Dr. Farmer was a
recipient of MSNJ’s Golden Merit
Award for 50 years of service to the
medical community.
Dr. Arthur W. Greenfield
At the grand age of 85, Arthur Wil-
liam Greenfield, M.D., died on Febm-
ary 25. 1984. Dr. Greenfield received
his medical degree from the Univer-
sity of Minnesota in 1925. He was a
member of our Bergen County com-
ponent and of the American Medical
Association. For 40 years, Dr. Green-
field had a private family practice in
Hackensack and was affiliated with
Hackensack Medical Center.
Dr. John H. Hermann
John Herbert Hermann, M.D., a re-
tired member of our Essex County
component, died on January 12,
1984. Dr. Hermann was born in
1891 and received his medical
degree from New York University
School of Medicine in 1914. During
his career. Dr. Hermann was af-
filiated with St. Mary's Hospital, Or-
ange, and was a member of the
American Medical Association.
Dr. Zdenek Kubes
Word has been received of the
death of Zdenek Kubes, M.D., a
member of our Essex County com-
ponent. Dr. Kubes was bom in 1912
and was awarded a medical degree
from Masaryk University, Czechoslo-
vakia in 1937. Dr. Kubes, an ob-
stetrician-gynecologist, was af-
filiated with Bayonne Hospital,
Greenville Hospital, Jersey City, and
Newark City Hospital. He was a
member of the American Medical As-
sociation and a Fellow of the Ameri-
can College of Surgeons.
Dr. Freeman W. Metzer
Freeman Weeks Metzer, M.D., died
on Febmary 5, 1984. Bom in 1904,
Dr. Metzer earned a medical degree
at the University of Pennsylvania
School of Medicine in 1931. A sur-
geon, Dr. Metzer was affiliated with
Zurbrugg Memorial Hospital, River-
side. Dr. Metzer was a member of our
Burlington County component and
of the American Medical Associa-
tion, and was a Fellow of the Ameri-
can College of Surgeons.
Dr. James J. Nobile
At the age of 74, James John
Nobile, M.D., a member of our
Hudson County component, died on
January 24, 1984. Dr. Nobile was an
internist in Hoboken since 1938,
and was affiliated with St. Mary’s
Hospital. Dr. Nobile was a graduate
of Georgetown University Medical
School in 1935. A member of the
American Medical Association, Dr.
Nobile was a Fellow of the American
College of Chest Physicians.
Dr. Abe D. Stutchin
On January 30, 1984, Abe David
Stutchin, M.D., died. Bom in 1922,
Dr. Stutchin received his medical
degree from Yeshiva Medical School,
New York, in 1959. A member of our
Passaic County component and of
the American Medical Association,
Dr. Stutchin was a family practi-
tioner. He was affiliated with St.
Joseph's Hospital and Medical
Center, Paterson, during his 24-year
career.
L. 81— NUMBER 5— MAY 1984
435
Author Information
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official organ of the
Medical Society of New
Jersey. The goals of The
Journal are educational
and informational. All
material published in The
Journal is copyrighted by
MSNJ.
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The educational content of each
issue appears as scientific articles,
based on research, original concepts
relative to epidemiology of disease,
and treatment methodology; case re-
ports based on unusual clinical ex-
periences; review articles; clinical
notes, succinct items on some
aspect or new observation or tech-
nique of a case experience; and
special articles, which include evalu-
ations, policy and position papers,
and reviews of nonscientific sub-
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tary (critical narration); medical his-
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pediatric briefs; nutrition update;
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are prepared by the Editor and by
guest contributors on timely and rel-
evant subjects; editorials are the re-
sponsibility of the author. The Doc-
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permits. The principal aim in the
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The style of reference is that of Inc\
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1. Goldwyn RM: Subcutanea
mastectomy. J Med Soc
74:1050-1052, 1977.
2. Dixon WJ, Massey FJ: Introd
don to Statistical Analysis. Nv
York, NY, McGraw-Hill, 1969,
42-48.
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Receipt of each manuscript will 3
acknowledged and a copy deliveiil
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Reprints may be ordered after e
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I
COMMUNICATIONS
All communications should >e
sent to the Editor, The Jounl
MSNJ, 2 Princess Road, L'v-
renceville, NJ 08648.
436
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSf
SEEKING
RADIOLOGY OFFICE PRACTICE
A Board Certified Radiologist with nine years hospital
based experience is seeking to buy into or buy out an
active private office radiology practice in Northern or
Central New Jersey.
Write: Box No. 71 JMSNJ
Two Princess Road
Lawrenceville, NJ 08648
Associate Medical Director
South Jersey office, major national firm, seeks As-
sociate Medical Director; part-time initially; eventual
ull-time career opportunity with competitive
salary/benefits; requires sound professional back-
jround; experience, or substantial interest in utilization
:ontrol/peer review/medical administration. Replies
strictly confidential. Reply to:
Box No. 80
JMSNJ
2 Princess Road
Lawrenceville, NJ 08648
COORDINATOR OF
MEDICAL AFFAIRS
‘Progressive” is the Word at .
RIVERVIEW MEDICAL CENTER, a 500
bed acute care facility located in Red
Bank, NJ on the Navesink River.
We are accredited by JCAH, NJ State
Dept, of Health and NJ Hospital Association. Our affilia-
tions include Brookdale Community College, Mon-
mouth County Vocational School, Seton Hall University
and Monmouth College.
This highly visible position will report directly to the
President of the Medical Staff, Executive Committee of
the Medical Staff and the Administrator.
The Coordinator, under the direction of the President
of the Medical Staff, and in conjunction with the Medical
Center Administrator, shall supervise the execution of
the By-laws of the Medical Staff, the Rules and Regu-
lations of the Medical Center, and all policies of the
Board of Governors. The Coordinator of Medical Affairs
shall insure the continuing excellence of patient care at
Riverview Medical Center.
Interested candidates kindly submit your resume in-
clusive of vitae, licensure, salary history, qualifications
and credentials to: Ms. Sharon K. Barrows, Personnel
Recruiter.
RIVERVIEW MEDICAL CENTER
35 Union Street, Red Bank, NJ 07701
Equal Opportunity Employer M/E
>L. 81— NUMBER 5— MAY 1984
To: Career OrienteH F
„ Can you accen, ,u Jfedldn.
fpr ~
S sC°mpeWi^ income
^'Practice insurance
™ lexible schedule
® CME credits
0 Qrbanandruraf settings
er SGasfho^W Y°rk’ Philadelphia and the
emergency departm ' 3 median/ or 9encV medicine
Ac*®?*
th«
GROUP PRACTICE
OPPORTUNITIES
BC/BE Family Practitioners for expanding
federally qualified HMO, serving 36,000
members from three delivery sites in Cos-
mopolitan South Jersey area. Congenial
staff of 30 full-time physicians, and 75 to 100
contracting specialists covering all dis-
ciplines. Excellent hospital facilities. Medical
school affiliation. Choice of pleasant living
conditions in suburban, rural, or semi-rural
communities. Superior schools. Easy access
to Philadelphia (15 minutes), New York City
(90 minutes), Jersey Shore (60 minutes),
Jersey Pine Barrens (20 minutes) and
Pocono Recreation Area (2 hours). Com-
petitive salary and comprehensive benefit
package.
Send Curriculum Vitae to Kenneth M. Car-
roll, M.D. Executive Vice President/Medical
Affairs, Health Care Plan of New Jersey, 165
Old Marlton Pike, Medford, New Jersey
08055.
437
CLASSIFIED ADVERTISEMENTS
GENERAL PRACTITIONER— Semi re-
tired, age 55, desires industrial, pharma-
ceutical or similar position. (201)
545-4339.
INTERNIST— Board eligible, general in-
ternist with extensive emergency room
experience. Seeking group practice of
internal medicine or emergency room
position. Northern NJ area Available July
1984. Please call 212-645-4616, Steven
Wolinsky, MD. Curriculum vitae and ref-
erences available upon request.
OB-GYN — Board certified, 35, experi-
enced, wants to relocate. Solo, group or
partnership. Available immediately. Box
No. 66, JMSNJ.
OB-GYN— Seeking group practice or
partnership. Completing 4th year resi-
dency at Louisiana State University
Medical Center, Shreveport, LA New Jer-
sey bom and educated. Available July
1984. Call 318-686-2095 home or
318-674-5000 hospital.
RADIOLOGIST — Board certified, trained
in general diagnosis, nuclear medicine,
special procedures, CT and ultrasound.
Available full or part-time. Group prac-
tice or hospital based, North or Central
NJ. Write Box No. 81, JMSNJ.
NEEDED CARDIOLOGIST/ INTERNIST
—Cardiologist needed for multi-specialty
Internal Medicine group in the South
Jersey area near Atlantic City. Salary
with eventual partnership. Excellent
benefit package. If interested, please send
curriculum vitae to Box No. 76, JMSNJ.
NEEDED FAMILY PHYSICIAN— Board
eligible, for partnership in one of the
largest family practice facilities in NJ.
Please send resume to Box No. 69,
JMSNJ.
NEEDED INTERNIST— With formal geri-
atric training or strong interest in
geriatrics to join same in NJ practice ap-
proximately thirty minutes from Man-
hattan. Send CV to Box No. 82, JMSNJ.
NEEDED PEDIATRICIAN— A well estab
lished pediatric office in Southern New
Jersey seeks a pediatrician-generalist or
subspecialist as an Associate. Write Box
No. 75, JMSNJ.
NEEDED PRIMARY CARE PHYSI-
CIANS— Private fee-for-service practice
in new, fully equipped suburban offices.
All personal supplies and management
services provided. This is an excellent op-
portunity for physicians with a good
' bedside" manner interested in develop-
ing a lucrative practice and still desiring
time for the pursuit of happiness. Reply
to Neighborhood Doctor Corporation,
901 Long Beach Blvd., Ship Bottom, NJ
08008.
NEEDED PSYCHIATRIST— For private,
multi-disciplined outpatient center near
Plainfield-Fanwood border. Part or full
time. Send CV to Bertram Warren, MD,
Union County Psychiatric Clinic, 1358
South Avenue, Plainfield, NJ 07062.
PEDIATRICIAN/ PRACTICE— Middle
age, board certified, planning to sell pri-
vate practice. Seeks part-time position.
Pediatric clinic or office. Prefer Mon-
mouth or Ocean County. Willing to work
nights and weekends. Write Box No. 73,
JMSNJ.
WANTED — RADIOLOGY OFFICE
PRACTICE— Board certified Radiologist
with nine years hospital based ex-
perience is seeking to buy into or buy out
an active private office radiology practice
in Northern or Central NJ. Write Box No.
71, JMSNJ.
WANTED— RADIOLOGY PRACTICE—
Interested in buying a radiology practice
in NJ. Write Box No. 83, JMSNJ.
PRACTICE FOR SALE— General Medi-
cine Practice, Central NJ, 45 minutes
from NY. Blend of office-nursing home
patients. Low overhead. Write Box No. 79,
JMSNJ.
PRACTICE FOR SALE— OB-GYN, im
mediately in Northern Monmouth Coun-
ty near two accredited hospitals, in
appealing residential community, will in-
troduce. Call 201-264-7763.
PRACTICE SPECIAL OPPORTUNITY—
Large beautiful office, fully furnished and
equipped. Excellent location at bus stop
and near hospital. Can serve 1 or 2 doc-
tors, other health career personnel or
other profession. Available due to physi-
cian’s death. Patients waiting, contact
Mrs. L. Friedman, 18th & Northampton
Sts., Easton, PA 18042. 215-252-6341.
HOUSE/OFFICE FOR SALE— Edison,
NJ. Immaculate 4 bedroom home set on
a fully landscaped Vi acre with attached
5 room doctor’s suite. Private entrance.
Ample parking. Choice location near
John F. Kennedy Medical Center.
S189.900. Call 201-549-0600.
HOUSE/OFFICE FOR SALE— Short
Hills. Ranch style home, 8 room, 3 baths,
professional office suitable for medical
office or lower level. 8650,000, Telephone
201-376-7455, call after 5 p.m.
FOR SALE OR RENT— Kearny. Fully
equipped and furnished medical office
building including patients’ records.
Comer location on main street. Call after
8 p.m. 201-746-1709.
FOR SALE OR RENT— For immediate
occupancy, new, modem, energy efficient
building, 500 to 2,000 square feet avail-
able. 31,000 residents within three mile
radius. Close to Philadelphia Atlantic
City. Central Jersey shore area Internists
and specialists needed. Ideal for main/
satellite office. Call 201-350-1008.
FOR RENT — Fully equipped, furnish*
physician’s office just 1 8 miles west
Atlantic City. Call 609-965-1600. Wri
Mrs. Marie Frank, 227 Philadelphia Av
Egg Harbor City, NJ 08215.
FOR RENT — Office space available
fully equipped internist’s office
Berkeley Heights. Further informatic1
call 201-376-8511, 9 am. -5 p.m. M-F.
FOR RENT— Office space, Southei.
Gloucester Township, Camden Count
Office suite in new medical buildin
1000 or 2000 square foot suites ava;
able. Located in rapidly growing, high'
desirable area near several large hosp
tals. Ideal for family practice or specials
Building to be completed late 1984. C;
Dr. Ribatsky 609-227-2221.
FOR RENT — Professional office space f<(
rent. Millbum prestigious building, 7/
square feet. On-site parking, on bi
route. Call 201-731-1900.
FOR RENT — Professional office for rer
approximately 710 square feet. Ne,
Dover General Hospital. Near route i
and 46. Morris County, NJ. Telephor
201-366-2557.
FOR RENT — Professional office for rer
furnished, located in the Ironbound se
tion of Newark. Available July 1984. Q
201-762-6781.
FOR RENT — Beautiful, completely fu
nished medical office on Old Short Hil
Road across from St. Barnabas Hospit;
Parking lot, 13.31 square feet. Laq
waiting room, 3 examining rooms, coi
sultation room. Yours alone, no elevator
A rare find. Write Box No. 84, JMSNu
OFFICE FOR RENT OR SHARE
Spacious, furnished 600-1500 squa
feet, ample parking. Hazlet-Holmdel an
close to hospital. Call 201-264-7763.
SUBLET SPACE— Office to sublet in pr
fessional building. Deptford/Woodbui
Call 609-853-8720.
OFFICE FOR SHARE— Hudson Coun
at two locations near hospitals ar
transportation. Call 201-864-7172.
OFFICE FOR SHARE— Morristown, cei
tral location. Near hospital, ful
equipped, newly decorated. All utilitit
included. Ample parking available. Ne;j
public transportation. Available immed
ately. 201-267-2555.
OFFICE SPACE TO SHARE— 101 0
Short Hills Road, West Orange. Aero:
from St. Barnabas Hospita
201-994-9277.
OFFICE TO SHARE— Westfield, centr
location. Near hospital, fully equipped a
traetively decorated. All utilities include
Ample parking available. Near publ
transportation. Available immediate!
201-267-2555.
.1
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE;
438
CLASSIFIED ADVERTISEMENTS
’ACE WANTED — Professional office SPACE WANTED — Family practice phy- FOR SALE — BOAT, 1 982 Sea Ray Sedan,
iaee to share. Physician needs two days sician looking for office in Union County fly bridge, head, shower all extras. 26 foot
•r week. Journal Square area, Jersey to share or rent. Please call Dr. K. Patel by 10 foot. Call 201-864-7172.
ty. NJ 201-684-5077. ‘ 201-344-1575.
\TE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
ORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
imbers, hyphenated words. Count name and address as five words, telephone number as one word, and "Write Box No. 000,
o JMSNJ" as six words. COPY DEADLINE: Fifth of preceding month.
Seeking new patients?
we are
SPECIALISTS
in
PUBLIC RELATIONS
FOR THE MEDICAL PROFESSION
for a confidential interview call —
(201) 531-7080
phyllis kessel associates
780 West Park Avenue, Oakhurst, N.J. 07755
It's A Major Medical Explosion
The Lakewood, Toms River and Point Pleasant hospitals
are all going ahead with major expansion programs . . .
Brlcktown to build new facility.
Cross River Professional Center
400 to 2,300 Square Feet
Medical Center
minutes to three major
hospitals
• Private entrances and all
services available
• Equipment leases available
BMffiYMOR ENTcRPI?I3D Protected
1200 River Avenue (Route 9), Lakewood, NJ 08701 • (201) 367-2226
!4 Mile South of Kimball
• $9 to $1 1 per square foot
• Graduated rent schedules
• Ownership options available
• Fully landscaped
• Centrally located and 10
Wanted: Physicians who prefer
medicine to paperwork.
We are looking for dedicated physicians, phy-
Spians who want to be, not salesmen, accoun-
ts, and lawyers, but physicians. For such
I lysicians, we offer a practice that is practically
i rfect, where in almost no time you experience
{spectrum of cases some physicians do not en-
< unter in a lifetime, where you work without wor-
i ng whether the patient can pay or you will be
| id, and where you prescribe, not the least care,
i r the most defensive care, but the best care.
If that is what you want, join the physicians who
I ve joined the Army. Army Medicine is the per-
Ijst setting for the dedicated physician. Army
liedicine provides wide-ranging opportunities for
the student, the resident, and the practicing phy-
sician alike.
Army Medicine offers fully accredited resi-
dencies in virtually every specialty. Army resi-
dents generally receive higher compensation and\
greater responsibility than do their civilian
counterparts and score higher on specialty exam-
inations.
Army Medicine offers an attractive alternative to
civilian practice. As an Army Officer, you receive
substantial compensation, extensive annual paid
vacation, a remarkable retirement plan, and the
freedom to practice without endless insurance
forms, malpractice premiums, and cash flow
worries.
Army Medicine:
The practice that’s practically all medicine.
FOR FURTHER INFORMATION CALL COLLECT:
1LT John J. Schafer, AMEDD Personnel Counselor, USA MEDDAC,
Fort Dix, NJ 08640 Phone: (609) 562-4271
An Equal Opportunity Employer
- 81— NUMBER 5— MAY 1984
439
Need A Temporary Physician?
CompHealth treats your practice as if it were our
own during: vacations, CMEs, recruiting, clinic
start-up or other absences.
Want Free Time While You
Practice Medicine?
Join CompHealth’s Locum Tenens Physician Group.
★
For further information about temporary coverage
or locum tenens practice opportunities, call:
jga CompHealth
A Physician Group
WILSON ROSS, Regional Administrator
244 East Hanover St.
Trenton, NJ 08608
Telephone: 609-392-1111
XTAX SHELTERS N
Just one of the personal
financial services 'j
available to you from the |!
physician’s bank.
• tax planning
• lines of credit
• equipment financing
• retirement planning
• money management
• cash flow • investments
• estate planning
Call or Write
Joseph J. Verbaro, Jr.
Senior Vice President
(201) 228-9770
FivTiivr
FINANCIAL AND TRUST SERVICES /
DIVISION OF SECURITY NATIONAL BANK & TRUST COMPANY
OF NEW JERSEY
101 Eisenhower Parkway
^^Roseland^New^ersey^7068^^dembe^lXL^^^
440
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
PranrlsCO
The Journal
f the Medical
Society of
lank Y. Watson, m.d
1984
r
Send this coupon
for no-obligation
information
off the savings
uder
tie Medical
Society off
Mew Jersey
Endorsed
Insurance
Plans
Check this list
against your
coverages . . . .
□ $5000 Monthly Guaranteed
Convertible Accident and Health
□ $10,000 Monthly Practice
Overhead Expense
□ $1,250,000 Term Life Insurance
□ $500 Deductible
COMPREHENSIVE
MILLION-DOLLAR MAJOR
MEDICAL PLAN— No other
coverage needed — Issuable to Age
69
□ $15,000 Deductible MILLION-
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MAJOR MEDICAL PLAN for
holders of Blue Cross and other
Major Medical Plans — Issuable
to Age 69
□ $100-a-day Hospital Income
Policy
□ $200,000 High Limit Accident
Plan (
I""”
E. & W. Blanksteen
Agency, Inc.
E. & W. Blanksteen
75 Montgomery St.,
Jersey City, N.J. 07302
(201) 333-4340
or (800) 742-2849
□ Keogh and Corporate Plan
NOW! $15,000 KEOGH
Name:
Address:
Tel. No..
Best Time To Call.
■he IBM Personal Computer
i tool for modern times
n the Medical Office.
[EDI-SCAN®, an Authorized IBM® Value-
dded Dealer for the Personal Computer
.ir Comprehensive $8,995.00 MEDI-SCAN In-office
lling And Accounting System Includes:
The IBM Personal Computer XT with 128K,
10 Megabyte hard disk.
The IBM Graphics Printer.
MEDI-SCAN software — customized for your
practice, including procedure numbers for state
tgencies. Generates accounting reports,
comprehensive patient statements, insurance
and third party forms.
Optional electronic paperless billing to third party
igencies, where applicable.
• raining — Complete in-office training for your
support — “HOT-LINE” 800 number for
continuous support.
' EDI-SCAN Single Source
iipport System
f£DI-SCAN’S unique, comprehensive hardware and software maintenance agreement guarantees continuing
; vice and repair, system updates and additional customization, plus in-office training — all from one source. Our
l :al training consultants and technicians are dedicated to giving you the best possible service.
1 M Personal Computer XTs are in stock in our local warehouses ready to be immediately installed. Over three
t ndred physicians are using the MEDI-SCAN System — join them in making the IBM PC-XT “A tool for modem
ties in the medical office.”
Networking available for group practices and clinics
would like to know more about the MEDI-SCAN
system on the IBM Personal Computer XT.
|Dr._
Address
Or call: 800-922-1021
In MA: 800462-1009
Send to: MEDI-SCAN
90 Madison Street, Worcester MA 01608
-ity State Zip
^hone ( )
Service centers currently in: New England • Mid Atlantic States • Mid Western States • California • Texas
'’MEDI-SCAN is a registered trademark of PAL Assoc. Inc.
’AL Associates is an Authorized IBM Value-Added Dealer for the Personal Computer.
IBM is a registered trademark of International Business Machines Corporation.
KOL. 81— NUMBER 6— JUNE 1984
441
June 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1766
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Hariy M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara, M.D. (1986) Salem
Henry J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Publication Committee
Paul J. Hirsch. M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi. M.D.
Robert M. MacMillan. M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R. Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gyneeol)
Joseph Apert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Afonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psyehiat)
Christine E. Haycock M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Henry R. Liss, M.D. (Neurosurg)
Geobel A. Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Alergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psyehiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) excep
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of Nei
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA, by the Hughes Printin
Co. Whole number of issues 963. Member’s subscription ($10) is included in Society dues. Rates for nonmember:
$20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, Tw
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and addition!
entiy office. Copyright 1984 by the Medical Society of New Jersey.
442
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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Features
449 Membership Newsletter
456 Professional Liability Commentary
46 1 Editorials
465 Hospital Governing Boards
469 Inaugural Address— Frank Y. Watson, M.D.
473 Farewell Address — Alexander D. Kovacs, M.D.
475 MSNJ Auxiliary— Mrs. William B. Gellman
476 Golden Merit Awards
Contributions
48 1 Cardiac Amyloidosis and Idiopathic Hypertrophic Subaortic Stenosis
RA. Daniels, M.D., R. Weinberg, M.D., A.F. Rangwala, M.D.,
G. Mintz, M.D.. Long Branch
487 The Smoking Cessation Reduction Action Program
N. Hymowitz, Ph.D., I. Laquatra, S. Karl, Newark
493 Promoting Compliance in Hypertensive Patients
P. Supino, EcLD.,A.R. Gotsch, Ph.D„ D. Van Harlingen, EcLD., J. Hebble,
Piscataway
50 1 Case Report: Hyperprolactinemia in a Patient with Pseudotumor
Cerebri
M. Goldman, M.D., and A. Rabin, M.D., Englewood
503 Pharmacological Basis of Therapeutics: Eicosanoids— Mediators of
Biological Functions
D.J. Wolff, Ph.D„ Piscataway
507 Impaired Physicians Program: Treatment Loan Fund
D.I. Canavan, M.D., Lawrenceville
Doctors’ Notebook
509 Trustees’ Minutes: April 15, 1984
510 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
511 AMNJ Report, Paul J. Hirsch, M.D.
511 New Members
5 1 2 Physicians Seeking Location in New Jersey
MSNJ Departments
515 CME Calendar
517 Letters to the Editor
518 Book Reviews
520 Obituaries
522 Information for Authors
On The Cover: Frank Y. Watson,
M.D., is the 192nd President of the
Medical Society of New Jersey. We
congratulate Dr. Watson and wish
him eveiy success during his
term.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE':
The Journal
of the Medical
Society of
444
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i. 81— NUMBER 6— JUNE 1984
445
Announcing a major advance
in cardiovascular therapy
CARDIZEM (diltiazem HC1)
30 mg and 60 mg tablets
CALCIUM CHANNEL BLOCKA1
from
Marion Laboratories
POTENT CORONARY
VASODILATION WITH A
DISTINCTIVE
HEMODYNAMIC PROFILE
CARDIZEM™ (diltiazem HCl)
causes little or no negative
^ inotropic effect
at recommended
jw doses while
m providing
J^potent %
j^coronary
Jw vasodilation.
Please see full prescribing information on last page of thi.
cardizem
(dilNazem HCI)
30 mg and 60 mg tablets
TM
INCREASES EXERCISE TOLERANCE,
REDUCES ANGINAL FREQUENCY* * WITH
A LOW INCIDENCE OF SIDE EFFECTS
Calcium channel blockade with CARDIZEM™ (diltiazem HCI)
produces changes in cardiovascular hemodynamics and
coronary blood flow that are of benefit in myocardial ischemia.
mm
IARDIZEM™ (diltiazem HCI) ALLOWS PATIENTS
TO SIGNIFICANTLY PROLONG EXERCISE
TOLERANCE, EVEN IN DEMANDING BRUCE
PROTOCOL EXERCISE TESTS1 (n - 15)
-dizem patients exercised longer
ore onset of pain!
l
b
-IN STAGE
5 METS)
k
STAGE 1
(4 METS)
STAGE 2
(6.5 METS)
STAGE 3
(10 METS)
P< 005
fES 3 6 9
TO ONSET OF PAIN
ontrol patients averaged 8.0 min. |£| Cardizem patients average
12
d 9.8 min.
This study is of special significance because
patients not only exercised longer but to the
next higher stage in the Bruce protocol.
A Bruce protocol with a run-in stage was used
for all tests. Each stage lasts three minutes.
In other studies, Cardizem produced
41% to 68% reduction of Prinzmetal’s
variant angina attacks?
tThis study is a report from one center in a multicenter study.
wKKKtssmmmm
erapy with Cardizem produced a
v incidence of side effects.
ilacebo-controlled trials (222 patients)
ducted in the United States, the incidence
idverse reactions reported during Cardizem
*apy was not greater than that reported
ing placebo therapy.
rences:
ol PE, Seagren SC, Bonanno JA, et al: The treatment of
ercise-inducible chronic stable angina with diltiazem: Effect
treadmill exercise. Chest 78 (Julysuppl): 234-238, 1980.
hroeder JS, Feldman RL, Giles TO, et al: Multiclinic
ntrolled trial of diltiazem for Prinzmetal’s angina. Am J Med
■227-232, 1982.
33, Marion Laboratories, Inc.
Those adverse reactions reported most frequently
with Cardizem in 959 patients in controlled and
uncontrolled U.S. trials have been:
• Nausea 2.7%
• Swelling/edema 2.4%
• Arrhythmia 2.0%
• Headache 2.0%
• Rash 1.8%
• Fatigue 1.1%
Other reactions reported infrequently (less than
1%) are listed in full prescribing information on
adjacent page.
* Please see adjacent page for full prescribing information.
L. 81— NUMBER 6— JUNE 1984
447
PROFESSIONAL USE INFORMATION
cardizem
(dilfiazem HCI)
30 mg and 60 mg tablets
DESCRIPTION
CARDIZEM™ (diltiazem hydrochloride) is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist). Chemically,
diltiazem hydrochloride is 1,5-Benzothiazepin-4(5H)one,3-(acetyl-
oxy)-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+) -cis-. The chemical structure is:
,OCH,
HCI
'N-
I "0
CH2CH2N(CH3);
Diltiazem hydrochloride is a white to off-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform.
It has a molecular weight of 450.98. Each tablet of CARDIZEM con-
tains either 30 mg or 60 mg diltiazem for oral administration.
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions during
membrane depolarization of cardiac and vascular smooth muscle.
Mechanisms of Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1, Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both
epicardial and subendocardial. Spontaneous and ergonovine-
induced coronary artery spasm are inhibited by CARDIZEM.
2. Exertional Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at sub-
maximal and maximal exercise work loads.
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-
contraction uncoupling in various myocardial tissues without changes
in the configuration of the action potential. Diltiazem produces
relaxation of coronary vascular smooth muscle and dilation of both
large and small coronary arteries at drug levels which cause little
or no negative inotropic effect. The resultant increases in coronary
blood flow (epicardial and subendocardial) occur in ischemic and
nonischemic models and are accompanied by dose-dependent
decreases in systemic blood pressure and decreases in peripheral
resistance.
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrio-
ventricular conduction in isolated tissues and has a negative inotropic
effect in isolated preparations. In the intact animal, prolongation of
the AH interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate/blood pressure product for any given work load. Studies
to date, primarily in patients with good ventricular function, have
not revealed evidence of a negative inotropic effect: cardiac output,
ejection fraction, and left ventricular end diastolic pressure have
not been affected. There are as yet few data on the interaction of
diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR pro-
longation was 14% with no instances of greater than first-degree
AV block. Diltiazem-assoclated prolongation of the AH interval is
not more pronounced in patients with first-degree heart block. In
patients with sick sinus syndrome, diltiazem significantly prolongs
sinus cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to
240 mg/day nas resulted in small increases in PR interval, but has
not usually produced abnormal prolongation. There were, however,
three instances of second-degree AV block and one instance of
third-degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed from
the tablet formulation to about 80% of a reference capsule and is
subject to an extensive first-pass effect, giving an absolute bio-
availability (compared to intravenous dosing) of about 40%.
CARDIZEM undergoes extensive hepatic metabolism in which 2%
to 4% of the unchanged drug appears in the urine. In vitro binding
studies show CARDIZEM is 70% to 80% bound to plasma proteins.
Competitive ligand binding studies have also shown CARDIZEM
binding is not altered by therapeutic concentrations of digoxin,
hydrochlorothiazide, phenylbutazone, propranolol, salicylic acid,
or warfarin. Single oral doses of 30 to 120 mg of CARDIZEM result
in detectable plasma levels within 30 to 60 minutes and peak
plasma levels two to three hours after drug administration. The plasma
elimination half-life following single or multiple drug administration
is approximately 3.5 hours. Desacetyl diltiazem is also present in
the plasma at levels of 10% to 20% of the parent drug and is
25% to 50% as potent as a coronary vasodilator as diltiazem. Thera-
peutic blood levels of CARDIZEM appear to be in the range of 50
to 200 ng/mi. There is a departure from dose-linearity when single
doses above 60 mg are given: a 120-mg dose gave blood levels
three times that of the 60-mg dose. There is no information about the
effect of renal or hepatic impairment on excretion or metabolism
of diltiazem.
effective in the treatment of spontaneous coronary artery spasm
presenting as Prinzmetal's variant angina (resting angina with
ST-segment elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated
Angina). CARDIZEM is indicated in the management of chronic
stable angina in patients who cannot tolerate therapy with
beta-blockers and/or nitrates or who remain symptomatic
despite adequate doses of these agents. CARDIZEM has been
effective in short-term controlled trials in reducing angina
frequency and increasing exercise tolerance, but confirmation
of sustained effectiveness is incomplete.
There are no controlled studies of the effectiveness of the con-
comitant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or con-
duction abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pace-
maker, (2) patients with second- or third-degree AV block, and (3)
patients with hypotension (less than 90 mm Hg systolic).
WARNINGS
1 Cardiac Conduction. CARDIZEM prolongs AV node refractory
periods without significantly prolonging sinus node recovery
time, except in patients with sick sinus syndrome. This effect
may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (four of 959 patients for 0.42%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2 Congestive Heart Failure. Although diltiazem has a nega-
tive inotropic effect in isolated animal tissue preparations,
hemodynamic studies in humans with normal ventricular func-
tion have not shown a reduction in cardiac index nor consistent
negative effects on contractility (dp/dt). Experience with the
use of CARDIZEM alone or in combination with beta-blockers
in patients with impaired ventricular function is very limited
Caution should be exercised when using the drug in such
patients.
3. Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4. Acute Hepatic Injury. There has been a single report in a
patient receiving 120 mg of diltiazem tid of marked transaminase
elevation (SGOT 4500, SGPT 2300) accompanied by hyper-
bilirubinemia (to 3 mg%), occurring after four days of treatment.
The enzyme abnormalities resolved entirely, and enzymes were
nearly normal a week after cessation of treatment. No rechal-
lenge was carried out, but the patient had no evidence of viral
hepatitis and received no other drugs but isosorbide dinitrate
No other similar liver injury has been reported in clinical
trials, but marketing experience in Europe has resulted in a
rechallenge-confirmed instance of hepatocellular injury. How-
ever, it should be noted that there have been further episodes
of raised transaminases in the absence of diltiazem in this
patient, so that the relationship to diltiazem of the abnormalities
is not completely clear. Other instances of transaminase eleva-
tion have been reported in Europe, but their relationship to
the drug is uncertain
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm.
CARDIZEM is indicated in the treatment of angina pectoris
due to coronary artery spasm. CARDIZEM has been shown
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried oi
to date, but it should be recognized that patients with impaire
ventricular function and cardiac conduction abnormalities hav
usually been excluded. Experience with an added beta-blocker i
also extremely limited
In domestic placebo-controlled trials, the incidence of advers
reactions reported during CARDIZEM therapy was not greater tha
that reported during placebo therapy.
In addition, the following have been reported infrequently an
represent occurrences which can be at least reasonably associate
with the pharmacology of calcium influx inhibition. In many case:
the relationship to CARDIZEM has not been established. The mo:
common occurrences, as well as their frequency of presentatioi
are nausea (2.7%), swelling/edema (2.4%), arrhythmia (2.0%
headache (2.0%), rash (1.8%), and fatigue (1.1%). In addition, tt
following events were reported infrequently (<1 0%). The order i
presentation corresponds to the relative frequency of occurrence
Cardiovascular: Flushing, congestive heart failure, bradycardi
hypotension, syncope, pounding heart.
Central Nervous Drowsiness, dizziness, lightheadedness, nervou
System: ness, depression, weakness, insomnia, confusin'
hallucinations.
Gastrointestinal: Vomiting, diarrhea, gastric upset, constipatio;
indigestion, pyrosis.
Dermatologic. Pruritus, petechiae, urticaria.
Other: Photosensitivity, nocturia, thirst, paresthesia;
polyuria, osteoarticular pain.
The following additional experiences have been noted
A patient with Prinzmetal’s angina experiencing episodes
vasospastic angina developed periods of transient asymptomai
asystole approximately five hours after receiving a single 60-n
dose of CARDIZEM
Experience in 959 patients taking oral doses of CARDIZE;
resulted in three cases (0.31%) of second-degree AV block a
one case (0.10%) of third-degree AV block at doses of 240
360 mg daily.
In rare instances, mild to moderate transient elevations of alkali!
phosphatase, SGOT, SGPT, LDH, and CPK have been noted dun1
CARDIZEM therapy A single incident of markedly elevated liq!
enzymes associated with symptoms was reported in a patient taki,
360 mg per day for four days. Drug was discontinued and enzym!
normalized within 1 week.
Bradycardia
PRECAUTIONS
General. CARDIZEM is extensively metabolized by the liver and
excreted by the kidneys and in bile. As with any new drug given over
prolonged periods, laboratory parameters should be monitored at
regular intervals. The drug should be used with caution in patients
with impaired renal or hepatic function. In subacute and chronic dog
and rat studies designed to produce toxicity, high doses of diltiazem
were associated with hepatic damage In special subacute hepatic
studies, oral doses of 125 mg/kg and higher in rats were associated
with histological changes in the liver which were reversible when
the drug was discontinued In dogs, doses of 20 mg/kg were also
associated with hepatic changes; however, these changes were
reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS.)
Uncontrolled domestic studies suggest that concomitant use of
CARDIZEM and beta-blockers or digitalis is usually well tolerated.
Available data are not sufficient, however, to predict the effects of
concomitant treatment, particularly in patients with left ventricular
dysfunction or cardiac conduction abnormalities; the effect of diltiazem
on serum digoxin levels has not been examined. The safety of the
combination of CARDIZEM and beta-blockers or digitalis is cur-
rently being investigated in well-controlled studies.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21-month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests. No intrinsic effect on fertility was observed
in rats
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates
There was an increased incidence of stillbirths at doses of 20
times the human dose or greater.
There are no well-controlled studies in pregnant women; there-
fore, use CARDIZEM in pregnant women only If the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation
Pediatric Use. Safety and effectiveness in children have not
been established.
OVERDOSAGE OR EXAGGERATED RESPONSE
Overdosage experiences with oral diltiazem have not been report!
Single oral doses of 300 mg of CARDIZEM have been well toleral:
by healthy volunteers. In the event of overdosage or exaggeral
response, appropriate supportive measures should be employ
in addition to gastric lavage. The following measures may
considered:
Administer atropine (0 60 to 1.0 mg). If there is
response to vagal blockade, administer isop
terenol cautiously.
Treat as for bradycardia above. Fixed high-deg
AV block should be treated with cardiac pacini
Administer inotropic agents (isoproterenol, do
mine, or dobutamine) and diuretics.
Vasopressors (eg, dopamine or levartere
bitartrate).
Actual treatment and dosage should depend on the severity!
the clinical situation and the ludgment and experience of the treat t
physician
The oral LDso's in mice and rats range from 415 to 740 mg,;
and from 560 to 810 mg/kg, respectively. The intravenous LD ' (
in these species were 60 and 38 mg/kg, respectively. The (.
LDso in dogs is considered to be in excess of 50 mg/kg, wli
lethality was seen in monkeys at 360 mg/kg. The toxic dose in r
is not known, but blood levels in excess of 800 ng/ml have
been associated with toxicity.
High-degree AV
Block
Cardiac Failure
Hypotension
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atherosclerotic Coron
Artery Disease or Angina Pectoris at Rest Due to Coron 1
Artery Spasm. Dosage must be adjusted to each patient's net
Starting with 30 mg four times daily, before meals and at bedti;
dosage should be increased gradually to 240 mg (given in divii <
doses three or four times daily) at one- to two-day intervals i| :
optimum response is obtained. The effectiveness and safet ,
dosages exceeding 240 mg per day are currently being investiga
There are no available data concerning dosage requirement jj
patients with impaired renal or hepatic function. If the drug nij.
be used in such patients, titration should be carried out v
particular caution.
Concomitant Use With Other Antianginal Agents.
Sublingual NTG may be taken as required to abort a1
anginal attacks during CARDIZEM therapy.
Prophylactic Nitrate Therapy -CARDIZEM may be sa1
coadministered with short- and long-acting nitrates, but t
have been no controlled studies to evaluate the antiani
effectiveness of this combination.
Beta-blockers. (See WARNINGS and PRECAUTIONS.
HOW SUPPLIED
CARDIZEM 30-mg tablets are supplied in bottles of 100 (;]
0088-1771-47). Each green tablet is engraved with MARION onl
side and 1771 engraved on the other CARDIZEM 60-mg sell
tablets are supplied in bottles of 100 (NDC 0088-1772-47). 1 1
yellow tablet is engraved with MARION on one side and 177 r ,
the other. ■ ‘
Issued IT
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES. INC
KANSAS CITY MISSOURI 64137
448
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE:
Membership
Newsletter
PHE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 12
3LUE SHIELD VIOLATES ANTITRUST LAW
A federal district court in Massachusetts has ruled
hat Blue Shield’s ban on balance billing by parti-
cipating physicians imposes an unreasonable re-
straint on competition.
In Massachusetts, Blue Shield provides coverage
mly when services are rendered by a participating
ihysician. Since Blue Shield holds the dominant
narket share, physician participation becomes a
natter of economic necessity rather than voluntary. All
ihysicians are reimbursed at the same maximum
irice level regardless of skill or training.
The court found that the restraint adversely impacts
m the patient’s choice of physician and affects
ompetition among physicians.
MANDATED ASSIGNMENT DEFEATED IN HOUSE
On April 12, 1984, the U.S. House of Representatives
onsidered a proposal to freeze Medicare reimburse-
ment for physician services for a year-coupled with
Mandated acceptance of Medicare assignment for
ervices to hospitalized patients. The House rejected
he proposal in a voice vote. It is likely the issue will
>e considered again in the fall.
ADVERTISING AND SOLICITATION PRACTICES
On March 14, 1984, pursuant to the authority of
fJ-SA 45:9-2, the Board of Medical Examiners
epealed the former text of N.JA.C. 13:35-6.10
egulating advertising and solicitation practices of
icensees of the Board of Medical Examiners, and in
ccordance with the applicable provisions of the
Administrative Procedure Act, the Board adopted in its
'lace under the same citation the text proposed and
'ublished at 16 N.J.R 32 on January 3, 1984, with
hanges not in violation of N.JAC. 1:30-3.5. Further,
ne Board voted to alert readers in the published notice
f adoption that a new provision restrictive of certain
tyles of advertising in public media will be proposed
i the next available Register (that is, a provision
rohibiting drawings, animations, clinical photo-
raphs, dramatizations, music or lyrics in radio or
,
television advertisements) which will be added to the
present adopted text as new section (m).
The other changes, deemed not to require
republication, are the following: grammatical
correction to N.JAC. 13:35-6.10 (d) and (1) to make
clear that the paragraph pertained to the Board of
Medical Examiners, and a spelling correction in f(2).
N.JAC. 13:35-6. 10(e) is modified in response to public
comments to make clear that traditional community-
based informational services such as Welcome Wagon
may continue to include announcements and
information or literature from licensees. Also, new
wording was adopted for N.JAC. 13:35-6. 10(h) based
upon the suggestion of New Jersey Bell Telephone
which advised that the proposed wording would result
in considerable expense to Board licensees in
advertising media such as telephone yellow pages; the
Board determined that, while all licensees must be
identified on professional stationery and at the office
location, advertisements intended for off-premises
display or circulation need list only the professional
service corporation or trade name along with nature
of practice, address or telephone number, and the
name of at least one of the practicing licensees. The
Board’s responses to other public comments is set
forth in a committee report which was reviewed and
adopted by the Board on March 14. The report is
available for public inspection. The Board’s
determination to continue to prohibit the advertising
of “free services” or the substantial equivalent of free
services (for example, “$5 examination”) was, as noted
in the report, supported by testimony presented at the
public hearing conducted on October 6, 1983. Not only
did respected and credible witnesses speak on the high
abuse potential of “free service” advertising done
within the confines of a physician’s office, but those
speaking in favor of it described the very effects that
the Board had feared as in fact happening in office
settings where certain practitioners were inducing the
public to come in with an offer of “free examination.”
Full text of the adoption follows (additions to the
proposal shown in boldface with asterisks *thus*;
deletions from the proposal shown in brackets with
asterisks *[thus]*).
)L. 81— NUMBER 6— JUNE 1984
449
13:35-6.10 Advertising and solicitation practices
(a) Definitions: The following words and terms when used
in this section shall have the following meanings unless the
context clearly indicates otherwise.
1. The term “advertisement" shall mean any attempt
directly or indirectly by publication, dissemination, or
circulation in print or electronic media which directly or
indirectly induces or attempts to induce any person or entity
to purchase or enter into an agreement to purchaser services,
treatment, or goods related thereto from a Board licensee.
2. "Board licensee” shall mean any individual holding a
license issued by the State Board of Medical Examiners.
3. The term “routine professional service” shall refer to a
service which a board licensee or professional association
routinely performs.
4. The term "print media" shall include newspapers,
magazines, periodicals, professional journals, telephone
directories, circulars, handbills, flyers, billboards, signs,
matchcovers and other similar items, documents or
comparable publications, the content of which is
disseminated by means of the printed word. The term shall
not include aerial displays.
5. The term “electronic media” shall include radio and
television, but shall not include communications made by
sound equipment from a motor vehicle.
6. The term “range of fees” shall refer to an expressly stated
upper and lower limit on the fees charged for services or
goods offered by a Board licensee.
(b) A Board licensee may provide information to the public
by advertising in print or electronic media
(c) A Board licensee who engages in the use of advertising
which contains any of the following shall be deemed to be
engaged in professional misconduct:
1. Any statement, claim, or format which is false,
fraudulent, misleading or deceptive;
2. Any misrepresentation of a material fact;
3. The suppression, omission, or concealment of any
material fact under circumstances which a Board licensee
knows or should know that the omission is improper or
prohibits a prospective patient from making a full and
informed judgment on the basis of the information set forth
in the advertisement;
4. Any claim that the service performed or the materials
used are superior to that which is ordinarily performed or
used in the profession;
5. Any promotion of a professional service which the Board
licensee knows or should know is beyond the licensee’s ability
to perform;
6. A technique or communication which appears to
intimidate, exert undue pressure, or to unduly influence a
prospective patient or consumer;
7. Any personal testimonial attesting to the quality or
competence of a service or treatment offered by a licensee;
8. The communication of any fact, data, or information
which may personally identify a patient;
9. An offer to pay, give, or accept a fee or other
consideration to or from a third party for the referral of a
patient;
10. Any print, language, or format which directly or
indirectly obscures a material fact;
11. Any statement offering gratuitious services or the
substantia] equivalent thereof, provided, however, nothing
herein contained shall be deemed to prohibit the rendering
by a Board licensee of professional services for which no fee
is charged.
(d) * [A] The* licensing board may require a licensee to
substantiate the truthfulness of any assertion or
representation set forth in an advertisement. Failure of a
Board licensee to provide factual substantiation to support
a representation or assertion shall be deemed professional
misconduct.
(e) A Board licensee shall not engage either directly or
through the use of any agent, employee, or representative in
in-person solicitation with a prospective patient or consumer.
This subsection shall not prohibit ‘licensee from offering
services through materials provided to a community service
organization which makes known the availability of all
professional services desiring to be listed; nor shall it
prohibit* the offering of services by a Board licensee to any
bona fide representative of prospective patients including
but not limited to employers, labor union representatives, oi
insurance carriers.
(0 Advertising making reference to or setting forth a fe<
shall be limited to that which contains a fixed or a statec
range of fees for specifically described routine professions
services or goods offered by licensees.
1. A Board licensee who advertises fees shall disclose a!
relevant and material variables and considerations which ar
ordinarily included in such a service so that the fee will b
clearly understood by prospective patients or consumers. ;;
2. In the absence of such disclosure referred to in (f)!|
above, the stated fees shall be presumed to include eveiythin
ordinarily required for such a service. No additional charge,
shall be made for an advertised service unless th
advertisement includes a specific delineation of addition;
services contemplated in the fee to be charged therefore.
(g) Offers of discounts or fee reductions shall state a bon
fide fee or range of fees against which such discounts are f
be made.
(h) * [All Board licensee advertisements and publi
representations shall contain the name and address c
telephone number of the Board licensee, professional servic
corporation, or trade name under which the practice i1
conducted and shall also set forth the names of all licensee
who are principals, partners, or officers in the firm or entiill
identified in the advertisement and the nature of thl
professional practice.] The name and nature of profession: !
practice of eveiy licensee practicing independently or as ajl
employee of another licensee or of a professional servic
corporation shall appear on professional stationery and she
be conspicuously displayed and kept at the entrance of tb •
place where the licensed practice is conducted*
(i) The responsibility for the form and content of ar,
advertisement offering services or goods by a Board license I
shall be jointly and severally that of each Board licensee wb -
is a principal, partner, or officer of the firm or entity identifie
in the advertisement.
(j) The time period during which an advertised fee wj
remain in effect shall be set forth on the face of tb
advertisement. In the absence of such disclosure, the effects I
period shall be deemed to be 30 days from the date of tlj
advertisement’s * (initial] final* publication.
(k) A video or audio tape of every advertisemei '
communicated by electronic media shall be retained by tlfj
Board licensee and shall be made available for review upc
request by the Board or its designee. A copy of af
advertisement appearing in the print media shall also 1]^
retained by the licensee and made available for review. T1
tapes and print media copies required to be retained by tb
subsection, shall be kept for a period of three years from tl
date of the last authorized publication or dissemination
the advertisement. *'
* (1) All Board licensee advertisements and publ; 1
representations intended to be displayed or circulated aw
from the office premises shall contain the name and addre j
or name and telephone number of the Board licensee or t I
professional service corporation or trade name under whi
the practice is conducted and the nature of the professior
practice. All such advertisements, including telepho
directory advertisements may, if desired, list only t
professional service corporation or trade name but mi
disclose the nature of the practice, and address or telepho
number, and the name of at least one of the princip
practitioners.*
*(m)* (Reserved)
* [1] (n) * Nothing contained in this section shall
construed to prohibit *[a] the* licensing board from adopti
additional regulations concerning advertising by Boe
licensees. To the extent that any conflict or inconsistency rr
arise between the provisions of this section and aj
subsequently adopted rule dealing more specifically with tj
same subject matter as set forth, such subsequent adopt
rule shall control.
H El
TWIN CLUB
One of the goals of the New Jersey Association
Twins’ Mothers Clubs is to assist researchers in a’
450
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
9
ay possible to learn more about development of twins,
he association maintains a Permanent Twin Registiy
ith approximately 700 names on file. The National
rganization of Mothers of Twins Clubs, Inc. has a
jrmanent listing of adult twins. If you are interested
1 doing twin research or if you know of anyone with
lat interest, please do not hesitate to contact the club.
ATIONAL ORGAN TRANSPLANTATION
CT— MEDICARE AMENDMENTS
The AMA and 24 medical specialty and hospital
ganizations, in a joint statement, called for the
Tetion of major Medicare amendments from H.R
380, the National Organ Transplantation Act. The
edicare amendments would allow the Secretary of
HS to ration any health care technology or procedure
/ establishing reimbursement criteria for Medicare
meficiaries, physicians, medical facilities, and the
>nditions under which the technology or procedure
>uld be provided. These Medicare amendments are
jot limited to transplantation and never received
jtention as to their impact during Subcommittee
tarings.
E CAREFUL
jThe State Board of Medical Examiners voted to
affirm the policy regarding the use of rubber
iignature stamps by doctors with the following
larification: “Any professional interpretation by a
fiysician, whether that physician be a pathologist or
diologist, requires the full original signature of the
pysician rendering that professional interpretation,
/ports of test results which have not required an
i dividual professional interpretation, such as but not
Inited to CBC, need not be individually signed.”
1 JBLIC OPINION/DOCTOR RELATIONS
Depending on to whom you listen the image of the
i sdical profession rides a roller coaster. Some surveys
;e reported to indicate individual physicians still are
1 Id in high regard by their patients. The same surveys
; >o point out that the opinion of the overall profession
5 ow signs of erosion.
Many of the complaints relate to what appears to be
bk of consideration and dehumanized relationships
1 tween the patients and the providers of medical care.
The profession is beleaguered by various political
; d economic forces according to John Corboy, M.D.,
i Hawaii Medical Journal. He suggests that
lysicians take a tip from their unschooled
(mpetitors and get back to basics. Try to utilize the
derwhelming therapeutic power of true concern,
t-ich, support, and personal reassurance. Take an
Ora minute for the magic; it’s veiy good medicine.
We have a collection of various media articles on the
(ctor-patient relationship that are enlightening. You
(a request copies by writing to MSNJ, c/o Public
illations. Two Princess Road, Lawreneeville, NJ
(648.
* W COMPREHENSIVE MAJOR MEDICAL PLAN
I tS LOWER COSTS FOR YOUNGER MEMBERS
/our Society now endorses a true, comprehensive
Wijor Medical Plan, administered by E. & W.
I
'•'L. 81 -NUMBER 6— JUNE 1984
Blanksteen, which provides complete medical care
protection in one package. Because of its $500
deductible and age-rated premiums, a full family under
40 can be fully covered for hospital and medical
expenses for under $1,000 a year. No Blue Cross or
other hospital coverage is needed when you have this
policy.
Here is a description of the Plan for members and
dependents who have not yet reached the age of
eligibility for Medicare:
After a $500 deductible, the Plan covers;
a) full semiprivate room cost (including full
intensive/coronary care);
b) all other hospital charges (except phone or TV);
c) 80 percent of all physicians’ and surgeons’ fees;
d) $64 each eight-hour shift for special nurses; and
e) 80 percent of prescriptions drugs, laboratory and
x-ray charges, physiotherapy, and local ambulance
charges.
You can choose this plan as your only hospi-
tal/medical/surgical/nursing protection, if only you
are willing to assume the following obligations
yourself:
1) the $500 deductible for each illness;
2) the difference between the full charge for special
nurses and the policy’s $64 per eight-hour shift;
3) 20 percent of physicians’ and surgeons’ fees; and
4) out-of-hospital mental disorders, which are not
covered.
For this comprehensive protection, your total annual
cost for family coverage, with children to age 25, is only:
If you are
Your family cost is
Under 40
$932
40-49
1,384
50-59
1,988
60-64
2,806
Special Medicare
Supplement is provided for Medicare-age
participants.
The new plan will enable a prudent member to
control his health insurance cost commitment and at
the same time control his own exposure to much of
the expense-risk of sickness or injury in the family.
E. & W. Blanksteen always is ready to help you to
answer any questions you may have. For information
(or a personal appointment, if you wish), call
201-333-4340 or, toll-free, 800-742-2849.
SOME INSURANCE PREMIUMS GO DOWN
The Society’s endorsed Professional Overhead
Expense Plan with E. & W. Blanksteen, through the
Nationwide, has just had its second rate decrease in
five years.
Overhead Expense policies help pay those expenses
pertaining to your practice when you are unable to
practice because of sickness or injury. These expenses
include the cost of malpractice insurance. Employees’
salaries, rent, or mortgage interest constitute the
major Overhead Expenses in the conduct of a medical
and surgical practice.
Without Overhead coverage, a physician must spend
savings or disability income insurance benefit
451
payments to keep a temporarily unproductive practice
going. At today’s cost levels, this can be next to
impossible.
If a disability should last longer than a month or two,
a physician who has too little Overhead insurance
coverage can find that he is forced to a premature
decision as to whether to keep his office and staff
functioning or to close the office, or at least reduce his
staff.
Most of these problems can be avoided simply by
bringing one's practice overhead benefits up to today’s
necessaiy levels. The time is propitious, since
premiums have been reduced for all participants from
9 percent to as much as 30 percent under this
endorsed Plan with Blanksteen and the Nationwide.
To calculate how much Overhead Expense insurance
you need, the technique is simple: A physician divides
the major expenses of his practice into monthf
portions — insurance premiums, employee salaries
rent or mortgage interest payments, taxes, utilities
accounting and legal retainers, telephone, ant
answering services. The sum of these represents th
cost of maintaining the practice during a disability
The recent premium reduction, plus the fact the
premiums are tax-deductible, makes the Society’s Pla
an exceptional bargain for all members.
Full information, as well as an application an
descriptive information and counseling are availabl
from E. & W. Blanksteen who may be reached t
calling, toll-free, 800-742-2849, or at 201-433-4340,
FINI
Why can’t life’s big problems come when we are 2
and know everything?
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the “con-
spiracy of silence” that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle” on a suffering colleague is indeed an ACT OF LOVE!
Call Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
452
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
you practice.
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program, Jf
for more information please call
(201) 456-3200.
The card that you can count on...
Blue Shield
of New Jersey
\VHV
medical, scien < maintains a
to information. ™^^rna,s,and
large colledion '^ jns|ant on.une
microfilm and p information
access to c0“n,^Lterized data
sources throu9 p one more
^^^be3Part
Of the AMA.
To Join, „KJ nr state medical
Contact your c°u W ■ 0f Member-
society or wnt®M°h Dearborn Street,
ShiP,Tutfoois 60610 or call collect,
Chicago, Illinois
(312)751-6196.
References:
1 . Stone PH, Turi ZG, Muller JE: Efficacy of nifedipine therapy for refractory angina
pectoris Am Heart J 104,672-681, September 1982.
2. Antman E, Muller J, Goldberg S, et al: Nifedipine therapy for coronary-artery
spasm Experience in 127 patients. N Engl J Med 302: 1269-1273, June 5, 1980.
BRIEF SUMMARY
PROCARDIA" (nifedipine) CAPSULES For Oral Use
INDICATIONS AND USAGE: I. Vasospastic Angina: PROCARDIA (nifediome) is indicated for the
management of vasospastic angina confirmed by any of the following criteria 1 ) classical pattern
of angina at rest accompanied by ST segment elevation, 2) angina or coronary artery spasm pro
voked by ergonovine, or 3) angiographically demonstrated coronary artery spasm In those patients
who have had angiography, the presence of significant fixed obstructive disease is not incompatible
with the diagnosis of vasospastic angina, provided that the above criteria are satisfied PROCARDIA
may also be used where the clinical presentation suggests a possible vasospastic component bu
where vasospasm has not been confirmed, eg, where pain has a variable threshold on exertion oi
in unstable angina where electrocardiographic findings are compatible with intermittent vaso
spasm, or when angina is refractory to nitrates and/or adeguate doses of beta blockers
II. Chronic Stable Angina (Classical Effort-Associated Angina): PROCARDIA is indicated foi
the management of chronic stable angina (effort-associated angina) without evidence of vasospasrr
in patients who remain symptomatic despite adequate doses of beta blockers and/or organic nitrate;
or who cannot tolerate those agents.
In chronic stable angina (effort-associated angina) PROCARDIA has been effective in controller
trials of up to eight weeks duration in reducing angina frequency and increasing exercise tolerance
but confirmation of sustained effectiveness and evaluation of long-term safety in those patients art
incomplete
Controlled studies in small numbers of patients suggest concomitant use of PROCARDIA ant
beta blocking agents may be beneficial in patients with chronic stable angina, but available mfor
mation is not sufficient to predict with confidence the effects of concurrent treatment, especially ir
patients with compromised left ventricular function or cardiac conduction abnormalities When in
troducing such concomitant therapy care must be taken to monitor blood pressure closely sinci
severe hypotension can occur from the combined effects of the drugs (See Warnings )
CONTRAINDICATIONS: Known hypersensitivity reaction to PROCARDIA
WARNINGS: Excessive Hypotension: Although in most patients, the hypotensive effect o
PROCARDIA is modest and well tolerated, occasional patients have had excessive and poorly tol
erated hypotension These responses have usually occurred during initial titration or at the time o
subsequent upward dosage adjustment, and may be more likely in patients on concomitant bet;
blockers
Severe hypotension and/or increased fluid volume requirements have been reported in patient:
receiving PROCARDIA together with a beta blocking agent who underwent coronary artery bypas:
surgery using high dose fentanyl anesthesia The interaction with high dose fentanyl appears to bi
due to the combination of PROCARDIA and a beta blocker, but the possibility that it may occurwitl
PROCARDIA alone, with low doses of fentanyl. in other surgical procedures, or with other narcotii
analgesics cannot be ruled out In PROCARDIA treated patients where surgery using high dosi
fentanyl anesthesia is contemplated , the physician should be aware of these potential problems and
if the patient’s condition permits, sufficient time (at least 36 hours) should be allowed fo
PROCARDIA to be washed out of the body prior to surgery
Increased Angina: Occasional patients have developed well documented increased frequency, du
ration or severity of angina on starting PROCARDIA or at the time of dosage increases The mech
amsm of this response is not established but could result from decreased coronary perfusior
associated with decreased diastolic pressure with increased heart rate, or from increased demam
resulting from increased heart rate alone
Beta Blocker Withdrawal: Patients recently withdrawn from beta blockers may develop a with
drawal syndrome with increased angina, probably related to increased sensitivity to catechoi
amines Initiation of PROCARDIA treatment will not prevent this occurrence and might be expecter
to exacerbate it by provoking reflex catecholamine release. There have been occasional reports o
increased angina in a setting of beta blocker withdrawal and PROCARDIA initiation It is importan
to taper beta blockers if possible, rather than stopping them abruptly before beginnim
PROCARDIA
Congestive Heart Failure: Rarely, patients, usually receiving a beta blocker, have developed heai
failure after beginning PROCARDIA Patients with tight aortic stenosis may be at greater risk fo
such an event
PRECAUTIONS: General: Hypotension: Because PROCARDIA decreases peripheral vascula
resistance, careful monitoring of blood pressure during the initial administration and titratio
ot PROCARDIA is suggested Close observation is especially recommended for patients alread
taking medications that,are known to lower blood pressure. (See Warnings.)
Peripheral edema: Mild to moderate peripheral edema, typically associated with arterial vaso
dilation and not due to left ventricular dysfunction, occurs in about one in ten patients treated wit
PROCARDIA This edema occurs primarily in the lower extremities and usually responds to diureti
therapy. With patients whose angina is complicated by congestive heart failure, care should betake
to differentiate this peripheral edema from the effects of increasing left ventricular dysfunction.
Drug interactions: Beta-adrenergic blocking agents: (See Indications and Warnings.) Experien
in over 1400 patients in a non-comparative clinical trial has shown that concomitant administrate
of PROCARDIA and beta-blocking agents is usually well tolerated, but there have been occasion:
literature reports suggesting that the combination may increase the likelihood of congestive heai
failure, severe hypotension or exacerbation of angina
Long-acting nitrates PROCARDIA may be safely co-administered with nitrates, but there hav
been no controlled studies to evaluate the antianginal effectiveness of this combination
Digitalis: Administration of PROCARDIA with digoxin increased digoxin levels in nine of twelv
normal volunteers The average increase was 45%. Another investigator found no increase in d
goxm levels in thirteen patients with coronary artery disease. In an uncontrolled study of overtw
hundred patients with congestive heart failure during which digoxin blood levels were not mea:
ured, digitalis toxicity was not observed Since there have been isolated reports of patients wit
elevated digoxin levels, it is recommended that digoxin levels be monitored when initiating, adjus
ing , and discontinuing PROCARDIA to avoid possible over- or under-digitalization
Carcinogenesis, mutagenesis, impairment of fertility: When given to rats prior to mating, nifi
dipme caused reduced fertility at a dose approximately 30 times the maximum recommended hi
man dose
Pregnancy: Category C Please see full prescribing information with reference to teratogenicity
rats, embryotoxicity in rats, mice and rabbits, and abnormalities in monkeys.
ADVERSE REACTIONS: The most common adverse events include dizziness or light-headednes:
peripheral edema, nausea, weakness, headache and flushing each occurring in about 10% of p:
tients, transient hypotension in about 5%, palpitation in about 2% and syncope in about 0.5"/
Syncopal episodes did not recur with reduction in the dose of PROCARDIA or concomitant antiai
ginal medication Additionally, the following have been reported muscle cramps, nervousnes:
dyspnea, nasal and chest congestion, diarrhea, constipation, inflammation, joint stiffness, shak-
ness, sleep disturbances, blurred vision, difficulties in balance, dermatitis, pruritus, urticaria, fi|
ver, sweating, chills, and sexual difficulties. Very rarely, introduction of PROCARDIA therapy w;.
associated with an increase in anginal pain, possibly due to associated hypotension
In addition , more serious adverse events were observed , not readily distinguishable from the na;
ural history of the disease in these patients. It remains possible, however, that some or many
these events were drug related Myocardial infarction occurred in about 4% of patients and conge
tive heart failure or pulmonary edema in about 2% Ventricular arrhythmias or conduction disturl
ances each occurred in fewer than 0.5% of patients.
Laboratory Tests: Rare, mild to moderate, transient elevations of enzymes such as alkaline pho
phatase, CPK. LDH, SGOT, and SGPT have been noted, and a single incident of significantly el
vated transaminases and alkaline phosphatase was seen in a patient with a history of gall bladd
disease after about eleven months of nifedipine therapy The relationship to PROCARDIA therapy
uncertain These laboratory abnormalities have rarely been associated with clinical symptom
Cholestasis, possibly due to PROCARDIA therapy, has been reported twice in the extensive wor
literature.
HOW SUPPLIED: Each orange, soft gelatin PROCARDIA CAPSULE contains 10 mg of nifedipm ■■
PROCARDIA CAPSULES are supplied in bottles of 100 (NDC 0069-2600-66). 300 (NDC 006'
2600-72), and unit dose (10x10) (NDC 0069-2600-41) The capsules should be protected fro
light and moisture and stored at controlled room temperature 59° to 77°F (15° to 25°C) in the ma
ufacturer's original container.
More detailed professional information available on request © 1982 , Pfizer In j
LABORATORIES DIVISION
PFIZER INC
454
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
"My daily routine consisted of
sitting in my chair trying to stay alive."
"My doctor switched me to
PROCARDIA M as soon as it became
available. The change in my condition
is remarkable."
"I shop, cook and can plant
flowers again."
"I have been able to do volunteer
work., .and feel needed and useful
once again."
PROCARDIA can mean the return to a more normal life
for your patients — having fewer anginal attacks,1 taking
fewer nitroglycerin tablets,2 doing more, and being more
productive once again.
Side effects are usually mild (most frequently reported
are dizziness or lightheadedness, peripheral edema,
nausea, weakness, headache and flushing, each occurring
in about 10% of patients, transient hypotension in about
5%, palpitation in about 2% and syncope in about 0.5%).
for the varied faces of angina
Procardia is indicated for the management of:
1 ) Confirmed vasospastic angina.
2) Angina where the clinical presentation suggests a possible
vasospastic component.
3) Chronic stable angina without evidence of vasospasm in
patients who remain symptomatic despite adequate doses of
beta blockers and/or nitrates or who cannot tolerate these
agents. In chronic stable angina (effort-associated angina)
PROCARDIA has been effective in controlled trials of up to
eight weeks' duration in reducing angina frequency and
increasing exercise tolerance, but confirmation of sustained
effectiveness and evaluation of long-term safety in these
patients are incomplete.
PROCARDIA
(NIFEDIPINE)
Capsules 10 mg
Please see PROCARDIA brief summary on adjoining page.
L. 81— NUMBER 6— JUNE 1984
455
Professional Liability
Commentary*
An obstetrics malpractice action
brought on behalf of the 21-
year-old daughter of a New Jer-
sey plaintiff contended that as a result of the negli-
gence of the defendant ob/gyn, who administered the
labor-inducing drug Tocosamine® (despite the fact
that it was contraindicated in that the mother was not
experiencing a difficulty with labor), the daughter sus-
tained cerebral palsy at birth and permanently will be
unable to walk, use her arms, or talk.
The plaintiffs contentions originally had been on
her own recollection of the events which transpired
and, in addition to the alleged improper adminis-
tration of the Tocosamine®, included allegations that
the defendant deviated in failing to perform a cesarean
section, and that the anesthesiologist deviated in ad-
ministering a “high” spinal anesthetic instead of a
saddle anesthetic, resulting in a dangerous drop in
blood pressure. The infant’s records which subse-
quently were located, established that the Tocosa-
mine \ in actuality, was administered. The defendant’s
own records indicated that there was an uneventful
labor and that the only difficulty was the tight core
wrapped around the neck of the infant at birth. Th
plaintiff deemed its documentary evidence was quit*
strong in that it established that the drug was admin
istered when the mother was not failing to contract
The plaintiff determined that this probably induce
abnormally long contractions which caused th
cerebral palsy. Additionally, a significant aspect of th
case contributing to both the finding of liability am
the size of the award, was the inconsistent position c
the defendant ob/gyn, who initially denied havin
prescribed the Tocosamine® and then maintained tha
there must have been a justification for giving it afte
the records were found. This inconsistency wa
thought to be especially damaging to the defendant'
case in light of the horrendous nature of the injurie
sustained by the child. The evidence of the extensiv
cost of permanent institutionalization, which at pref
ent amounts to $30,000 per year, also was significar
in the size of this award. The award was more tha
$2 million greater than the insurance coverage and th
plaintiff had made a timely demand of the carrier tl
pay the amount equal to the limits of coverage. Thi
demand was refused until the trial already had corr
menced when the defendant offered a settlement of
minimum of $100,000 if the defendant prevailed an
the policy limits if the plaintiff prevailed and the awar
was greater than these limits. The plaintiff declined 1
accept this offer. The plaintiffs position is that thi
offer clearly established the physician’s willingness t
settle and that the bad faith refusal lay with the carrit
and not with the physician. (New Jersey Verdict R<
view and Analysis, 1984)
$2 MILLION AWARD GRANTED
A 21 -year-old New Jersey woman has accepted
medical malpractice award of more than $2 millio
from a juiy that found her physician did not diagnos
an intestinal ailment in time to prevent major surger
The jury found that the defendant physician did m
diagnose the condition of ulcerative colitis in sufficiei
time to prevent the need for an operation in which tl:
plaintiffs entire colon and rectum had to be remove (
At age 16 the plaintiff first complained to her ph
sician of rectal bleeding in March 1979.
According to the plaintiff s court depositions, si ,
was given medication and told to return in two weel
if the symptoms did not subside. In a deposition, si
said her condition seemed better so she did not retmi
for a followup visit until 1 1 months later, when tl
bleeding recurred. The plaintiffs condition worsen*)
until she had to be hospitalized over New Year’s wee
end of 1981 with a severe infection of the colon. Who
her condition did not improve, surgery was perform* i
three weeks later.
Plaintiff s attorneys contended during the trial th
the physician’s failure to diagnose the ulcerative colit
led to the severe colon infection which led to the st
gery. He said that the surgery is irreversible and tj
best medical science can offer his client is an operati*
*This item from the Department of Professional Liability Cc
trol, MSNJ, was prepared by James E. George, M.D., J.D., at
A Ronald Rouse who are, respectively, Director of the Depa
ment and Director of Special Projects.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
456
to place a pouch used for excreted wastes inside rather
than outside the body.
Court records indicate that the plaintiff had offered
to settle the case for $1 million, the full amount of the
physician’s insurance coverage, prior to trial. (Asbury
Park Press, February 4, 1984)
VERDICT FOR FAILURE TO DIAGNOSE BREAST
CANCER
A medical malpractice action brought by a 65-year-
pld woman contended that as a result of the negligent
failure of the defendant pathologist to diagnose breast
.cancer, the condition was not detected until some 13
months later, resulting in a significantly diminished
'probability of survival, the performance of a total
'Halstead mastectomy (rather than less radical sur-
gery), and the requirement for 3 years of chemotherapy
leather than the typical course of such treatment
which would continue for 6 months only). The defen-
dant did not dispute that a misdiagnosis had occurred.
The plaintiff had a 20-year history of fibrocystic dis-
ease which entailed the relatively frequent presence of
oenign growths on the left breast. Following the re-
moval of a lesion, six slides were prepared by the defen-
dant who diagnosed a benign condition. Thirteen
months later, a lesion was detected below the left
Dreast and testing confirmed that the plaintiff had a
rather advanced case of breast cancer. The plaintiffs
expert oncologist maintained that based upon a review
pf the slides utilized by the defendant in his diagnosis
>f a benign growth, it was evident that the defendant
lad deviated. The expert related that the slides de-
picted cancer-type cells which were lined up in “Indian
‘ile,” clearly evidencing a malignancy. The expert main-
ained that based upon the slides, no other valid
liagnosis could possibly be made.
The plaintiffs treating immuno-oncologist from
Sloan-Kettering Memorial Hospital, New York City,
maintained that during the 13-month period which
dapsed until the condition was diagnosed correctly, it
leteriorated from a malignancy which probably could
lave been treated with a modified radical mastectomy
o a condition which required the removal of a large
lortion of the chest wall and a great many lymph nodes
n the arm. The physician maintained that had the
(malignancy been diagnosed by the defendant in a time-
ly manner, only six months of chemotherapy would
lave been required and that the plaintiffs chances of
recovery would have been quite good. He maintained
|hat as a result of the deviation, the plaintiff is in a
>rogram requiring three years of chemotherapy which
till is continuing. The physician maintained that be-
cause of the delay in diagnosis, the chances of a recur-
ence are approximately 70 percent and contended
hat in the event of such a recurrence, the plaintiff
>robably will die. The defendant’s expert oncologist
onceded that a recurrence probably would be un-
datable, but maintained that the chances of such a
Recurrence are only 40 to 50 percent.
The plaintiff contended that she has suffered a
sychological injury which largely stemmed from the
ict that the malignancy probably could have been
reated successfully. Her treating therapist, a psy-
£
ehiatric social worker from New York City, related that
the plaintiff withdrew from a therapy group comprised
of breast cancer patients because the contrast between
the relatively favorable prognoses in the other women
in the group, whose cancer had been detected in a
timely manner, and her own prognosis, filled her with
great consternation. The social worker maintained
that the psychological condition probably never will
improve. (New Jersey Jury Verdict Review and
Analysis, Vol. IV, No. 16, Jan. 23, 1984)
DID YOU KNOW . . .
Eighteen of those physicians dropped from MSNJ for
failure to complete the CME credits account for 32
malpractice claims? A breakdown showed: 1 1 physi-
cians with 1 claim; 1 with 3 claims; 3 with 4 claims
each; 1 with 5 claims; 1 with 7 claims; and 1 with 8.
When three pediatricians in New York sued to collect
$61 in unpaid medical bills, they triggered a $5 million
malpractice suit? The parents of a former patient al-
lege that the doctors mistreated their daughter’s ear
problem, which began when she was six months old.
Although the physicians treated the child for nearly
three years, the parents say there was no improvement
in her hearing or in the speech impediment resulting
from the ear problem. The parents claim that when
they requested another opinion, the doctors angrily
terminated the relationship — and the couple left
without paying their bill. The pediatricians have since
dropped the collection suit, but the malpractice suit
still is pending.
By age 45, the pattern of malpractice susceptibility
for ob/gyns— one of the most vulnerable of the special-
ties— is fairly well-established? Some 25 percent, age
45 and older, never have been sued; about 30 percent
have been sued once; and nearly 18 percent have been
sued twice. ( Medical Economics, February 6, 1984)
In Januaiy, the New York State Society of Internal
Medicine, in conjunction with a commercial insurance
carrier, began offering some members a plan that will
reduce malpractice premiums by 1 7 to 20 percent? But
eligibility is controlled tightly; the Society must certify
that the doctors do not subspecialize. Internists who
paid $4,600 to $10,200 for $1 million/$3 million cov-
erage in 1983 now can have the same coverage for
$3,800 to $8,400. And those who take a 1 2-hour course
on the risk management sponsored by the Society get
another 10 percent off. (Medical Economics, February
6, 1984)
Out-of-hospital child birth centers, which generally
are staffed by nurse-midwives, are increasing in
number? According to Cooperative Birth Center
Network of Perkiomenville, Pennsylvania, there cur-
rently are 105 such centers in 31 states, 25 percent
of which are less than a year old, with prospects for
300 more in the near future.
Northbrook Indemnity Company of Illinois, a wholly-
owned affiliate of Allstate Insurance, will be under-
writing professional liability coverage for medical
groups exclusively through Charles Stedman Group of
Sarasota, Florida? According to Stedman, “Medical
clinics are much preferred underwriting risks.” (Medi-
cal Liability Monitor, December 24, 1983)
DL. 81— NUMBER 6— JUNE 1984
457
Protection
th Benefits
a Lifetime
ONCE- DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, JNDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA— either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets—
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING
CAPSULES
The appearance of
INDERAL LA
AyersL
capsules is a registered
trademark of
Ayerst Laboratories.
\ \
A
jUST ONCE EACH DAY
FOR SIMPLIFIED CORE
THERAPY IN ANGINA
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
s
80
mg
120
mg
160
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL" LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used, in the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the cateeho amine .nducetl increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic :
pressure and systolic election period The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of paiftiSnd
increased work capacity. *
In dosages greater than required for beta blockade, INDERAL also exerts a quinidine-iike
or anesthetic-like membrane action which affects tho cardiac action potential Ice sqnifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established. Beta-
adrenergic receptors have been demonstrated in the piaf vessels Of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For exampfe, in patients wftm Severely'
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension; INDERAL LA is indicated in the manage-
ment ot hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking theiji
prior to maior surgery is controversial. It should be noted, however, that the impaired abiILf
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesth.iij
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of t;-
receptor agonists and its effects can be reversed by administration of such agents,
dobutamme or isoproterenol. However, such patients may be subject to protracted se>
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported 1
beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the -
pearance of certain premonitory signs and symptoms (pulse rate and pressure changers
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be nj|
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroid ,
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sympLi,
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function tel
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have t,«
reported in which, after propranolol, the tachycardia was replaced by a severe bradycsii
requiring a demand pacemaker. In one case this resulted after an initial dose of 5^|
propranolol.
PRECAUTIONS. General: Propranolol should be used with caution in patients with imps1:
hepatic or renal function. INDERAL is not indicated for the treatment of hyperten j
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Pati ;
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal >
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart dise I
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re -
pine should be closely observed if INDERAL is administered The added catecholarr -
blocking action may produce an excessive reduction of resting sympathetic nervous aci r:
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthos !:
hypotension.
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals t a
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studie i*
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of signify It
drug-.mdue.ed texrcity There were no drug-related tumorigenic effects at any of the dos;
levels. Reproductive studies in anirna's did not show any impairment of fertility that ,
' attributable to the drug
jP(00n&0:y Pregnane. Category C. INDERAL has been shown to be embryotoxi i
animal studies atj doses about 10 times greater than the maximum recommended human d i
There are no adequate and wett-conitoited studies in pregnant women INDERAL sh
be used during pregnancy o’niy if the potential benefit justifies the potential risk to the ft
Nursing Mj$8$rs: INDERAL is excreted in human milk Caution should be exercised w I
INDERAL is arBlIsterad to a nursjng woman
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most 'adverse effects have been mild and transient and tjs.
rarely required the withdrawal of therapy,
Cardiovascular : bradycardia, congestive heart failure; intensification of AV block; h
tension; paresthesia of hands; thrombocytopenic purpura, arterial insufficiency, usually o
ratynauatype. jar "W"
Central Nervous System: ctfgwffdedness; mental depression manifested by insorr j
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; vi i
disturbances; hallucinations; an acute reversible syndrome characterized by disorientatio I
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, :
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarr ; ,
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with acij
and sore throat, laryngospasm and respiratory distress
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytop|.
purpura
Auto immune In extremely rare instances, systemic lupus erythematosus has t
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male irf
tence, and Peyronie’s disease have been reported rarely. Oculomucocutaneous read,
involving the skin, serous membranes and con|unctivae reported for a beta blocker (practj
have not been associated with propranolol.
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride!
sustained-release capsule for administration once daily. If patients are switched from INDEj
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapi]
effect is maintained INDERAL LA should not be considered a simple mg for mg substitutj
INDERAL INDERAL LA has different kinetics and produces lower blood levels. Retitration:
be necessary especially to maintain effectiveness at the end of the 24-hour dosing intej
HYPERTENSION — Dosage must be individualized. The usual initial dosage is 8G
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage ma;
increased to 120 mg once daily or higher until adequate blood-pressure control is achia
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage Oj
mg may be required. The time needed for full hypertensive response to a given dosarj
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERA’*
once daily, dosage should be gradually increased at three to seven day intervals until optnj
response is obtained Although individual patients may respond at any dosage level;
average optimum dosage appears to be 160 mg once daily In angina pectoris, the valuej
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few wT
(see WARNINGS).
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDERA;
once daily The usual effective dose range is 160-240 mg once daily. The dosage maN
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response il
obtained within four to six weeks after reaching the maximum dose, INDERAL LA the)
should be discontinued. It may be advisable to withdraw the drug gradually over a pem|t
several weeks.
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group an.°
limited to permit adequate directions for use.
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laborali >
8833 }
I
AYERST LABORATORIES
New York, N.Y. 10017
THE JOUFLNAL OF THE MEDICAL SOCIETY OF NEW JERSE
:
Ayerst
460
Editorial
Frank Y. Watson, M.D.
—192nd President
Frank Y. Watson, M.D., will serve as the
192nd President of the Medical Society
of New Jersey.
Frank Y. Watson, M.D., of Glen
Ridge, will serve as the 192nd
President of the Medical Society
f New Jersey. Bom in Charlotte, North Carolina, Dr.
/atson received his premedieal education at Duke
niversity and his medical education at the University
f Maryland School of Medicine. Following an in-
imship at Charlotte Memorial Hospital, he volun-
;ered for active duty in the United States Navy. During
pe Korean War, he served as a Battalion Medical Of-
cer in the First Marine Division and participated in
ie numerous military operations of that unit includ-
ing the amphibious assault at Inchon, the liberation
if Seoul, and the winter offensive into North Korea. For
iis service, he was awarded a Letter of Commendation
|y the Secretary of the Navy.
Dr. Watson is certified in anatomic and clinical
iathology by the American Board of Pathology, having
?ceived his residency training at Charlotte Memorial
ospital. Prior to entering private practice in 1961 in
fontclair, he was on the faculty of SUNY-Downstate
ledical Center serving as surgical pathologist at Kings
ounty Hospital. He is clinical associate professor of
athology, UMDNJ-New Jersey Medical School. He is a
lember of the medical staff of The Mountainside Hos-
jital and has been director of the department of
pthology since 1973.
Since entering practice. Dr. Watson has been very
active in various areas of organized medicine. He has
served as president of the medical staff and ex-officio
member of the board of trustees of The Mountainside
Hospital, president of the Essex County Medical So-
ciety, delegate to the House of Delegates of the Medical
Society of New Jersey, member of the Board of T rustees
of the Medical Society of New Jersey, ex-officio member
of the Board of Trustees of the New Jersey Hospital
Association, and alternate delegate from the Medical
Society of New Jersey to the American Medical Associa-
tion House of Delegates. He is area chairman for New
Jersey and Delaware of the Inspection and Accredita-
tion Program of the American Association of Blood
Banks.
Dr. Watson especially is interested in political action
regarding legislation affecting health care and in the
administrative and leadership roles of physicians in
the health care system. He has served as chairman of
the New Jersey Medical Political Action Committee,
and is a member of the American Academy of Medical
Directors.
Dr. Watson is married to the former Carolyn D. Wolfe,
of Glen Ridge. They met as classmates in medical
school, were married shortly after graduation, and
have pursued separate medical careers. Carolyn also is
certified in anatomic and clinical pathology by the
American Board of Pathology, has subspecialized in
cytopathology, and is codirector of the division of
cytopathology of the department of pathology at Mount
Sinai School of Medicine, New York. Her recent ap-
pointment as alternate delegate to the American Medi-
cal Association House of Delegates by the American
Society of Cytology makes the Doctors Watson the only
husband-wife team in the American Medical Associa-
tion House of Delegates.
The Doctors Watson are the proud parents of four
children: James, David, Bruce, and Lisa James and his
wife, Marsha promise to present them with their first
grandchild soon. The Doctors Watson also are the
proud former foster parents of three Cuban children:
Nydia Maciques Webb, and Joe and Matt Borrajero,
who as teenagers, escaped from Cuba in 1961. The
Doctors Watson enjoy the challenges of the pursuit of
their medical careers, and a full and rewarding family
life.
The Medical Society of New Jersey congratulates
Frank Y. Watson, M.D., and wishes him every success
during his term as president.
PL. 81— NUMBER 6— JUNE 1984
461
Editorial
Kudos to The Journal,
Its Staff, and Others
The Journal of the Medical Society of New
Jersey has been singled out for national
commendation from Sandoz, Inc. and
from the New Jersey Writers Conference.
For the second year in a row. The
Journal of the Medical Society
of New Jersey has been singled
out for national commendation. The Journal was
granted a Special Award in the ninth annual Sandoz
Medical Journalism Competition. A check for $250
and a certificate were presented at the Medical Society
of New Jersey’s Annual Meeting by a representative of
Sandoz, Inc.
At the 17th annual New Jersey Writers Conference
on March 24, 1984, The Journal was awarded the
Author’s Citation for “William Carlos Williams: Com-
memorative Issue” by the Alumni Association of the
New Jersey Institute of Technology.
As of Januaiy 1984, the American Diabetes Associa-
tion appointed Arthur Krosnick, M.D., as editor-in-
chief of Diabetes Forecast a bimonthly publication for
persons with diabetes, their families, and for non-
professional readers interested in the subject.
Geraldine Hutner, managing editor of The Journal
gave birth to a son (7 lbs. 2 oz., 19'/2 inches) on March
5, 1984. Gerri and her husband, Jonathan Husch,
named their new star Benjamin. Congratulations from
us all!
We feel compelled to single out Gerri, Dorothy J.
Griffith, and Elizabeth and Joseph Cookson for superb
services to The Journal. The chairman, Paul J. Hirsch,
M.D., and his Committee on Publication have provided
guidance at its best, and the Editorial Board, individu-
ally and collectively, as well as many ad hoc manuscrj
and book reviewers, unstintingly have granted expi
peer review of all scientific material.
Vincent A. Maressa J.D., and James E. George, M.
J.D., who respectively provide the Membership Nev
letter and the Professional Liability Commentaiy, a
collectively prepare the Hospital Governing Boar
columns, have done a magnificent job. They are ;j
sisted ably by Martin E. Johnson and A. Ronald Rou
We owe a debt of gratitude to President, Dr. All
ander A. Kovacs, Dr. Paul J. Hirsch, Dr. Stanley
Bergen, Jr., Gale Wayman, and Dr. David I. Canav;
for monthly features and columns. Special items <j
beautifully presented by faculty members of UMD1
Dr. Richard J. Rapkin and colleagues (Pediatric Brie!
Dr. Bruce McL. Breckenridge and colleagues (Pham'
cological Basis of Therapeutics); and Dr. Hermi
Baker and colleagues (Contemporary Clinical Nut
tion). Numerous book reviewers regularly share th *
reactions to publications for our readers, and we o
them a huge debt.
Finally, I must single out Dr. Avrum L. Katch.i
whose foresight, skill, and judgment, along with yS
counted hours of reading, writing, telephoning, ai
editing, made the William Carlos Williams co
memorative issue what it was.
Awards go to the Medical Society of New Jersey, a !
to The Journal as a publication. But unrestricll
gratitude goes to all the above and more. A
462
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
Sditorial
Selection of Blue Cross/
Blue Shield Trustees
Vincent A. Maressa, j.d.
Should the selection of Blue Cross/Blue
Shield trustees become a subscriber
right?
Should the selection of Blue
Cross/Blue Shield trustees be-
come a subscriber right?
Recently, Arthur Bernstein, M.D., Secretary of the
edieal Society of New Jersey, shared with me a copy
testimony delivered to a congressional committee
viewing federal law on HMOs. The speech was pre-
nted by Mary Nell Lehnhard, Vice-President of the
phonal Blue Cross/Blue Shield Association, on April
1984.
Ms. Lehnhard began by reciting the Blues’ allegiance
the HMO concept. Then, she proceeded to criticize
Ie HMO Act because it requires a qualified HMO to
ive a governing board of which one-third are HMO
irollees. Her reasoning is that this requirement
ould prevent the Blues from running federally quali-
‘d HMOs and the Blues would have to create separate
ijitities for that purpose.
As a corporate manager and businessman, I under-
and what Ms. Lehnhard is saying, but I am not sym-
J.thetic to her position. The requirement that enrol-
ls have a significant minority position on the govem-
g board is a desirable feature. After all, they are pay-
g the premiums and should have a say in the man-
• ,ement of the companies. I suspect that what really
Ik 81— NUMBER 6— JUNE 1984
distresses her is the fact that enrollees would have
access to data and decisions normally made in secret,
but for which they must pay the price. Their access
to the data and the right to vote might mean that the
professional managers of the Blues would be required
to justify their decisions. They simply are not used to
functioning in that fashion.
Blue Cross/Blue Shield structure in New Jersey is
a case in point. For all practical purposes, they have
merged; they cover over three million New Jersey resi-
dents. They are an insurance company, but by defi-
nition are not either a stock company or a mutual
company. In a stock company, the stockholders vote to
elect directors and consider annual reports. In a
mutual company, the policyholders vote to elect direc-
tors and consider annual reports. In the New Jersey
Blues, the trustees vote to elect themselves and the
“subscribers" as the Blues so fondly call them are
without voices and vote. Participating physicians and
hospitals are also without voice and vote. The Blues
do not hold annual meetings to which subscribers or
participating physicians and hospitals are invited.
Isn’t it time the Blues gave their "subscribers" an
opportunity for an inside view of operations and policy
formation?
463
i
Doctors: Write your own prescription
to cure insurance pains . . .
R. Prescription
Prescription
Name MSNJ Member
Name
Address
MSNJ Group
Blue Cross/Blue Shield
Major Medical and
Dental Insurance
that provides:
- Flexible plans
- Comprehensive benefits
- Low, competitive rates
- Centralized Administration
Designed and Administered by
(DONALD F SMITH (V ASSOCIATES)
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERJ
464
Hospital Governing
boards*
Cost of Medical Care
James E. George, m.d., j.d.
The newest focus of hospital involvement
is the cost of medical services provided
in the hospital. Hospital corporations in-
creasingly are concerned with financial
matters that were once the sole province
of the private staff physician.
Since the mid-1960s, courts
across the nation have extended
the legal responsibility of the
>spital governing board into areas that once were the
elusive domain of the physicians on its medical staff,
many jurisdictions today, the hospital corporation
is legal responsibility for monitoring the quality of
edical care provided in the hospital. Various quality
surance and peer review programs, and increased
rutiny of appointments to the medical staff, are two
amples of increased hospital involvement.
The newest focus of hospital involvement is the cost
medical services provided in the hospital. Re-
onding to pressures from the federal government
id the insurance industry, hospital corporations in-
easingly are concerned with financial matters that
;re once in the sole province of the private staff physi-
ian. A recent Maryland case illustrates this evolving
lend.
The case of Ratino v Medical Services of the District
Columbia (Blue Shield), 718 F.2d 1260 (1983), in-
Ived John Ratino, M.D., a plastic surgeon, who had
edical staff privileges at Holy Cross Hospital in Silver
>ring, Maryland. Dr. Ratino, who was not a Blue
lield participant, for some time required his patients
sign a written agreement to pay his charges for
rviees to be rendered, the amount to be determined
:er the medical care was provided. The form Dr.
Ratino used provided in part: "It is . . . understood that
such fees may exceed amounts allowed by the fee
schedules of insurance companies ... or any other in-
dividual or Fee Review Commission not present when
the care or surgery is rendered. This specifically in-
cludes such fee designations as usual and customary
for similar care or surgery rendered by doctors without
similar special training. Thus, the patient’s liability
includes any and all differences between the amounts
paid by insurance or other third parties and the fee
charged ”
Dr. Ratino used this form in his practice and also
used this form when providing care in response to his
on-call duty to the hospital’s emergency department.
The Montgomery County Medical Society received a
number of complaints concerning Dr. Ratino’s use of
this form prior to performing on-call emergency room
treatment.
Subsequently, in March 1977, the Montgomery
County Medical Society sent a letter to area hospital
administrators asking them to suppress such conduct
in their emergency departments. The letter did not
specifically mention Dr. Ratino.
In response. Holy Cross Hospital advised the Mont-
gomery County Medical Society that the hospital had
an “open door” policy with respect to charity care. In
1978, Holy Cross’s Executive Committee directed Dr.
Ratino to cease using the form in question in the Holy
Cross Hospital.
Dr. Ratino then brought legal action in federal court
against the hospital, various officers of the Montgom-
ery County Medical Society, and Blue Shield. In his
suit, he alleged that Blue Shield’s “usual and custom-
ary insurance plan” with its provision for Medical So-
ciety peer review of medical charges, constituted illegal
price fixing in violation of antitrust laws. He also al-
leged that all the defendants had conspired illegally to
restrain him from using his “consent form” in con-
junction with providing services in the Holy Cross Hos-
pital.
The United States District Court for the district of
Maryland granted summary judgment in favor of all
the defendants. It ruled that the form contract used
by Dr. Ratino was illegal and in violation of public
policy. It also found that Holy Cross Hospital, in direct-
ing Dr. Ratino to stop its use, had not reacted to the
Medical Society’s letter but rather was merely unilat-
erally carrying out its long established policy of provid-
ing care to patients regardless of their ability to pay.
The court also found no evidence of anticompetitive
purpose on the part of any of the defendants, but
rather “an attempt on the part of medical care or-
ganizations to implement their own policies aimed at
safeguarding the health and welfare of emergency
room patients.” Dr. Ratino appealed.
The United States Court of Appeals, fourth circuit,
upheld the district court in its ruling that the activities
of the defendants disapproving Dr. Ratino’s use of the
form contract did not constitute an illegal conspiracy
to restrain trade. The appellate court overruled the
district court, however, with regard to Dr. Ratino’s al-
*The material for this column is eoedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, J.D.,
Executive Director, MSNJ: and James E. George, M.D., J.D.,
Director of Professional Liability, MSNJ.
'
«
)L. 81— NUMBER 6— JUNE 1984
465
legations of price fixing. It ruled that further legal
proceedings were necessary to determine whether the
Medical Society’s practice of peer reviewing “un-
reasonable fee” determinations by Blue Shield, in actu-
ality, was illegal price fixing.
The current uncertain climate with regard to in-
surance and other reimbursement mechanisms, in-
cluding Medicare, makes it all the more likely that
hospitals will involve themselves with the way physi-
cians practice medicine. Hospitals perceive that their
financial health, to a greater degree than ever befoi
is dependent on the activity of the medical staff. Ec
nomic realities must be recognized and dealt with 1
both the hospital and the medical staffs.
Whether attempts to resolve differences in this v<
atile area will result in cooperation or conflict betwe
the hospital and the medical staff remains an op<
question. It sincerely is hoped that these complex prc
lems can be mutually negotiated in an evolutions
rather than a revolutionary fashion.
466
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERff
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Inaugural Address*
Frank Y. Watson, m.d., glen ridge
Frank Y. Watson, M.D. , the 192nd President of the Medical Society
of New Jersey , presented this inaugural speech at the Annual
Meeting in May.
This is a very special moment for
me. I am deeply honored that
this House of Delegates has
losen me to be the 192nd President of this dis-
nguished Medical Society. I am also most pleased
ith the opportunity for service to others this position
rovides. Over the years, I have found that helping
thers has brought me much pleasure and satisfac-
on. For me, the practice of medicine has been one
reat love affair, exceeded only by my love for my bride
ad medical partner of 35 years. The position of Presi-
ent of the Medical Society of New Jersey gives me
ndreamed of opportunities to serve the profession I
early love. For these opportunities, I thank you from
ie veiy bottom of my heart. I promise you I will give
) the job my very best efforts. I will need help and I
ecept the offer of assistance from Dr. Kovacs.
hroughout the ages, physicians have heard the
hallenge:
1 “Doctor, please do all that you can.”
That cry for help is very familiar to you. Each of you
as heard it countless times.
It comes from people who are suffering, and deeply
•arful for their very lives.
It is the ultimate cry for help! Not long ago, this cry
>r help brought only simple measures of support and
aeouragement. There was very little effective treat-
ment a physician could give.
In cases of serious illness, the outcome was prompt.
Either the patient recovered, or his condition rapidly
worsened, and he passed away.
Today, this ultimate cry for help triggers a response
that is quantum levels above the response of yesterday.
Over the years, the collective response to that eiy has
led to the development of the most comprehensive
health care system the world has ever known. .
Physicians have provided the leadership; and the
American people have provided the resources.
Thousands of modem hospitals have been built in
all parts of this country. These magnificent institu-
tions of service to mankind are equipped with the most
modem technology our scientists can develop. The
pharmacies are cornucopias of medicines so effective,
they are called miracle dmgs.
Our unsurpassed medical education system has
provided over 7 million superbly trained health care
professionals that give the very best health care to the
vast majority of the 230 million Americans.
Today, Americans are receiving more health care of
a higher quality than any people in history. They have
less disease, are ill for shorter periods of time, are living
longer, and are enjoying a quality of life at a higher level
than ever before.
How has this been done? Not by a commitment to
cut costs; not by religious dogma; not by governmental
‘Presented at MSNJ's Annual Meeting, May 4, 1984.
OL. 81— NUMBER 6— JUNE 1984
469
fiat; not by competition of the sort found in the com-
mercial marketplace.
It was done by cooperation and teamwork! Yes, coop-
eration among the many parts of American society:
The medical profession, the scientific community, our
religious institutions, our educational institutions,
our business community, and yes, even our govern-
ment.
Banded together as a team, they identified their
mission, defined the goals necessary to achieve that
mission, and then worked cooperatively doing what
each does best to build the most effective health care
system that man has so far devised.
That, I like to think, is the American way.
And I repeat, the resources for all of this have been
willingly provided by the American people; 321 billion
dollars (10.5 percent of our GNP) are devoted to health
care each year. Health care has become our third larg-
est industry.
The guidelines for this great achievement were
simple, direct, and exactly what you would expect.
The mission was to free our fellow men of all prevent-
able and curable disease.
The attainment of this mission was to be through
the pursuit of four goals.
Goal 1 was to prevent disease wherever we can.
Goal 2 was to cure disease whenever possible.
Goal 3 was to provide humane care and comfort to
all of our people with yet incurable diseases.
Goal 4 was to continue, with all possible speed, re-
search into the causation, cure, and prevention of the
still incurable diseases.
We have made considerable progress, but we still
have a long way to go. In moments when things are
not going well, I sometimes wonder if a world free of
disease is really achievable!
Then I think of the eradication of small pox and my
optimism returns!
With the capacity and the momentum now in our
health care system. I believe we are on the verge of
unprecedented progress in the eradication of diseases
affecting mankind. To interfere with this at this time
would be a blunder of historic dimensions.
As American citizens, we all can take pride in this
accomplishment, viewing it not only as very sound
stewardship of the vast wealth with which this nation
is blessed, but also pointing to it as yet another exam-
ple of what free people in a democratic society can
achieve.
And yet as physicians we recognize that there is still
much to be done.
We recognize that there are still many Americans
who do not have equal access to the superb health care
services now available to the vast majority of Ameri-
cans. This is curable and I am confident it will be.
We recognize that there are still many diseases for
which we have no satisfactory treatment; and that the
humane supportive care of people with these diseases
is enormously expensive. This is money well spent
until our research efforts can bring relief.
We recognize that there are many diseases that are
absolutely preventable and yet they continue to occur
with alarming frequency and consume enormous
amounts of the resources allotted to health care. This
is a major challenge to our public health system. In-
creased efforts would minimize this situation.
We recognize that the choice of unhealthy lifestyle*
by all too many Americans results in the occurrence
of many of these absolutely preventable diseases, ant
accounts for a significant part of the cost of healtl
care. This is a major challenge to both our publi
health and our educational systems.
We recognize that an increasing number of Amen ;
cans are living longer than ever before and are reach i
ing the ages at which health care consumes a dis i
proportionately large amount of national resources
with a disappointingly small return in longevity anj
increased quality of life.
The solution to this problem is a challenge of im
mense dimensions that requires the combined effort
of all segments of society.
While recognizing that the American people hav*
made a greater effort and have achieved more than an
other people in the pursuit of that ultimate dream c
all men, a world free of disease, we are very much awar
that the continuing increase in the cost of this pursuit
has attracted the interest and concern of leaders in a
segments of our society.
We are now faced with allegations of duplication
excessive utilization, and gross inefficiencies in th
health care system. This frequently is referred to as fa
that must be rendered from the system as fat i
rendered from pork in the making of lard.
With such vague, unclear, and often inaccurate view i
of the conditions in the health care system, a whol
spectrum of solutions to these alleged problems ar
being foisted upon us.
I am particularly concerned when solutions tend ti
be riflelike in approach aimed at only one aspect of th
problem.
An example of the basis for my concern are som
remarks by Governor Kean at the First Session of th
National Governors Association Winter Meeting, Feb
ruary 26, 1984.
His remarks dealt almost exclusively with the cost
of health care services and their alleged negative im
pact on federal and state budgets, on the America*
economy, and on the cost of doing business in th]
United States. The Governor stated; “If American bust
ness is to sustain our economic recovery, if busines ;
is to put our workers back to work, then we must brinji:
health care costs under control.” The Governor wa
strangely silent about the fact that health care in th
United States is the third largest industiy and one oj
the top three in New Jersey. Over 7 million healtl]
professionals provide health care to the 230 millioi
Americans. Another 14 million Americans play a sup
porting role to those 7 million health professionals
While there may be some negative aspects regardin
health care costs, and while economic benefit is cer
tainly not the primary reason for having a health car
industiy, the economic impact of an industry provid
ing employment either directly or indirectly to 2
million Americans should at least be acknowledge!!
and placed in perspective, in any discussion of th
impact of health care on the American economy.
The Governor also shared some points he learned a
a hearing of health financing experts that he and Go\
emor Lamm, of Colorado, convened in December.
Governor Kean reported; “Of the projected increas
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
470
n costs of health care by 1990, 57 percent will be due
jo general inflation, 7 percent due to medical care infla-
ion, and 8 percent due to population increases. That
eaves 28 percent due to changes in medical technology
jnd patient care use and treatment practices. If we are
|o have any impact, it will be on this 28 percent of the
ncrease."
He then commented at length on several ways to
Tipact on the 28 percent due to changes in medical
echnology and patient care use and treatment prac-
ices. The ways discussed included controlling high
echnology (CAT scanners and NMRs), controlling low
echnology (routine lab tests and procedures and
rugs), and controlling the number of physicians and
heir specialization. All of the discussion dealt with the
eduction of costs. No comment regarding the allevia-
ion of illness was made and there was no mention as
d what might be done to impact on the 57 percent
f the increase in health care costs due to general
lflation, an area that is much more in the realm of
ovemment than any medical matters he mentioned.
The Governor's comments regarding the problem of
ae number of physicians and their specialization is
s follows:
“Our biggest problem is not numbers, but the fact
lat fully 85 percent of physicians are specialists, a
■vel higher than any other country in the world. These
re the doctors using high technology— often, in fact,
efined by that technology. One of our witnesses in the
•ecember hearing found that a general internist can
-iple his net income if he has a heavy, but justified
aseload of routine EKGs, chest x-rays, lab tests, and
igmoidoscopies, compared to colleagues who did none
f these, but saw 15 percent more patients,
yneeologists, urologists, and gastroenterologists earn
to 12 times as much per hour when they use their
■chnologies.
"Given these incentives, is it any wonder that our
ledieal system performs more surgery and invasive
iagnostic procedures than any other country in the
orld? One witness said in December, There are not
lough coronary arteries for the cardiologists.’”
These comments with their obvious inconsistencies
low a gross lack of understanding of the subject. It
sobering indeed to realize that those comments were
tade by the Governor of our state.
Now it is not my intent to take the Governor to task
•day regarding his remarks at the National Governors
ssociation Winter Meeting. This is not the proper
rum, and furthermore, the Governor is not here,
uch matters are best dealt with face to face.
By referring to the Governor’s remarks, however, I
ave tried to make the point that the provision of
?alth care is being discussed in forums other than
edieine, by persons other than health professionals,
ho often have a mission and goals different from
lose of the medical profession, and who frequently
ave enormous power, which they are not averse to
ling to deal with problems as they see them in the
health care system.
It, therefore, is necessaiy for us, as physicians, to not
only “do all that we can” to provide the very best of
health care possible in the one-on-one doctor/patient
relationship, we must also, “do all that we can” to be
a part of all discussions and all decisions regarding
health care wherever those discussions are being held
and wherever those decisions are being made.
"To do all that we can” also means we must learn
our way around in the political arena the halls of
government, the boardrooms of industry, and the do-
main of the health care administrators, for it is in
those forums that the major decisions regarding
health care are now being made.
Such opportunities are occurring with increasing
frequency. We must seize those opportunities and
make the most of them. Communication between the
Medical Society, various agencies of government, busi-
ness, and health care institutions is steadily growing.
There are now frequent contacts with the Com-
missioner of Health, the Health Department, members
of Legislature, the Governor’s Office, the State Board
of Medical Examiners, the New Jersey Hospital As-
sociation, and the New Jersey Business Group.
In addition, more than ever before physicians are
working with administrators in hospitals, HMOs,
PPOs, and other health-related facilities as well as with
representatives of other groups of the American people.
The efforts of the American Medical Association to
develop a health policy agenda for the American people
is a prime example of such teamwork.
When challenged to “do all that we can,” we must
always remember (we must never forget) that as phy-
sicians, we are the primary advocate for our patients,
not only at the bedside and in our office, but also in
all places where the discussions and decisions regard-
ing health care are held and made.
As the primary advocate for our patients, we must
support those actions that advance our mission and
our goals, and we must vigorously oppose those ac-
tions that endanger our mission and our goals.
In closing, I repeat: I believe the mission of the medi-
cal profession is to free people of all preventable and
curable diseases.
I also believe that to accomplish that mission, we
must continue to pursue four goals, all of which have
stood the test of time.
Goal 1 is to prevent disease wherever we can.
Goal 2 is to cure disease wherever possible.
Goal 3 is to provide humane care and comfort to all
of our people with yet incurable diseases.
Goal 4 is to continue with all possible speed, re-
search, and development into the causation, cure, and
prevention of those diseases still unconquered.
I believe that we will continue to have the full sup-
port of the American people so long as they know and
believe that we are fully committed to that mission and
these goals. Let us never leave them in doubt!
“Doctor, please do all that you can."
)L. 81— NUMBER 6— JUNE 1984
471
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: 3- 1
Farewell Address: An
Accounting of My Stewardship*
Alexander D. Kovacs, m.d., scotch plains
This address is an accounting of his stewardship , as Alexander
D. Kovacs , M.D., completes his year as President of the Medical
Society of New Jersey.
According to St. Luke, Chapter
16, a certain rich man called
upon his steward thus, “Make
in accounting of thy stewardship for thou canst be
steward no longer.”
I no longer can be your steward, and so I shall make
my accounting. There are so many things to do as
^resident of a state medical society that the momen-
:um can spin you in an endless circle unless you make
t go in one direction. The direction I chose to carry
)ut my stewardship was to attempt to rally the mem-
bers into a unified whole.
1 wish I could say that I succeeded 100 percent, but,
did not. There has been some pretty creditable move-
ment, however.
This past year we collected more money for political
:ampaigns than ever before and we were noticed in
state politics. This year we introduced a package of
egislation which, if passed, will begin to correct some
of the inequities of the present professional liability
situation. At least now we are in a position to talk to
some of our legislators about these bills. No one is so
aaive as to believe that a campaign contribution buys
a politician’s vote. What it does get you is an opportuni-
ty to present your case. We have a good case and a good
opportunity. Let us not waste it. We now must concen-
trate our efforts on this package of bills and not frag-
ment our energies on other less important legislation.
Don't forget, these politicians have other interests
besides our bills. We should be interested in and sup-
port some of their other efforts if we are to hope for
their support for our package.
We also managed to stick together long enough to
prevent a fee schedule from being imposed upon us as
part of the latest auto insurance law in New Jersey; and
we certainly have stuck together, 1 am proud to say,
on the issue of a voluntary freeze on fees. The positive
reaction to that request on the county, state, and na-
tional level has been outstanding.
Concerted action by the AMA and by doctors all over
the country has brought about the defeat of the
nefarious Rostenkowski amendment in Congress. If we
had lost that fight, we would have lost the right to
practice in our own hospitals.
Those were some of the battles we won. We have had
some losses too. Disciplinary actions by hospital gov-
erning boards as well as malpractice awards must be
reported to the State Board of Medical Examiners.
One year ago we were involved in a discussion with
the government on how best to treat the indigent pa-
tient. We still are. They keep coming up with ideas like
capitation, and we keep talking about the high price
of emergency room care, and the beautiful simplicity
of a modest but respectable fee for the private sector.
We have not yet spoken with one voice on the whole
‘Presented before the House of Delegates at the Annual Meet-
ing, May 4, 1984, Atlantic City.
VOL. 81— NUMBER 6— JUNE 1984
473
new structure of medical care which has grown so
visibly in New Jersey this past year — the freestanding
urgicenters, surgicenters, and hospital satellites. We
almost seem to be paralyzed by these new develop-
ments. This is no time to stand around open-mouthed;
while we do, others are making the regulations and
administrative decisions. We have to find a method to
handle these alternate care entities which will be in
the best interests of our patients, or we will not have
any patients to worry about.
There is so much that needs to be done. One year
is not enough to accomplish solid results. There is not
enough time to bring developing relationships into
bloom. I believe one year was fine in the days when we
were not so constantly under the gun. But in today’s
climate, some consideration should be given to making
the presidency a two-year term.
I do have some confidence that good foundations
have been laid for continuing negotiations with the
various agencies and entities involved in our pro-
fessional lives.
Our relationship with the New Jersey State Board of
Medical Examiners is less hostile than it used to be.
There continue to be differences — it is not possible for
an organization whose purpose is physician advocacy
always to be in tune with an organization whose
purpose is physician regulation. The present problem
regarding the scope of practice for chiropractors is an
illustration of that occasional disharmony.
Also, we have achieved some measure of respect-
ability in the eyes of the New Jersey State Department
of Health. We cannot, of course, take all the credit for
that. Commissioner Goldstein certainly has done his
share to keep the lines of communication open. On our
end, there has been a significant effort to serve on
committees with Health Department personnel as we
grope together toward solutions for some very tough
problems. While we may not be singing the star role,
at least we have moved out of the chorus.
I submit to you, my friends, that the future of our
profession lies in our willingness to recognize the legit-
imate interests of others in the health care business.
We cannot agree with everything they propose but we
have to be willing to work with them if we expect them
to agree with anything we propose.
One of the most rewarding of the presidential duties
is the opportunity to visit with you on your home
grounds. I wish to thank all of the county societies who
invited me to attend their meetings. In every county
I found some concerned, aware physicians. I wish there
were more. The biggest problem this profession has is
the apathy of its members. I was chagrined to find how
many physicians fail to appreciate the seriousness of
our problems and to accept that they individually and
collectively have a role to play in their solutions— and
that role comes to something more than maintaining
the status quo and complaining about their leaders!!
I know you share my concern about these determined^
uninformed.
There are serious problems to be faced. We canno
hide from them. They leap out from every newspape i
and television set. We must try to help cope with tb
rising cost of care. We have to have the courage to tell
people that costs will continue to rise despite fe«
schedules or fee freezes until this country accepts tb
plain fact that increasing numbers of elderly patient
cannot be treated with the full range of medical tech
nology without increasing costs.
We must face the problem of providing medical can:
for the least fortunate among us, and we must tell th<
story of the thousands of hours of free care we alread
contribute.
We must face the problem of the increased numbe i
of young physicians who have a right to expect to maki >
a living after years of study and sacrifice. We must no
turn our backs on these men and women.
None of these problems have been neglected during
this past year, but they require endless effort and dedi
cation if solutions are ever going to be forthcoming
We must all continue actively to support our leader
as they struggle to find answers to these and a hos
of other difficult issues.
When I became president I had the good fortune t(
succeed Howard Slobodien, M.D. I wish to publicb
thank Howard for being a staunch supporter anc
friend this past year. I hope I will be as helpful to Di
Watson. Dr. Costabile served ably as chairman of tb
Board of Trustees, and I wish to acknowledge his as
sistance.
There are others I wish to thank, not so much fo
what they did for me, but for what they did for you
the entire Board of Trustees and other members o
councils and committees who gave up their Sunday:
and their days off to come to Lawrenceville. Withou
the dedication of these few, we would not survive a:,
a profession. You owe them more than you can eve
repay.
Thanks is also due to a truly remarkable staff. Vin
cent Maressa is one of the most respected executive
directors in the United States. He makes you proud t<
come from New Jersey. The value of people like Dian;
Gore, Marie Fisher, and Eileen Pfeiffer to our pro
fession and our Society cannot be measured.
My personal thanks to that most gracious of ladies!
Ida, my wife. She has been cheerful and charming
through this busiest of times, and I can only humbP
acknowledge how much I owe to her patience and gooc
humor.
Finally, I thank you, the delegates, for the opportuni
ty to serve as your President.
;
m
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
474
MSNJ Auxiliary
G
race Scribner Gellman is the
58th President of the Medical
Society of New Jersey Auxiliary,
he assumed leadership of the Auxiliaiy on May 5.
ormerly Grace Scribner, a graduate of the Aultman
iospital School of Nursing, Canton, Ohio, Mrs.
iellman attended Ohio University, Athens, and Kent
tate University, Kent.
She married the late William B. Gellman, M.D., after
e finished his internship at Aultman Hospital. He
tarted his general practice and surgery in Wood-Ridge
nd was affiliated with Beth Israel Hospital, Passaic,
nd South Bergen Hospital, Hasbrouck Heights.
Dr. and Mrs. Gellman worked as a team in the early
ears of their marriage in addition to raising three
hildren — Alexander C„ a urologist in Denville: Michael
an aerospace engineer and naval aviator who
jmed to medicine and is finishing his residency in
nesthesia; and Mrs. Martha Braff, a biology major
'om Skidmore College, Saratoga, now living in Pitts-
)rd. New York, where her husband, Steven P. Braff,
I.D., practices radiology.
Grace has been involved in volunteer and organiza-
on work for many years. She was a charter member
f the South Bergen Hospital Women's Guild and
?rved as its first president. She was active in the
ergen County Medical Society Auxiliary, serving in its
arious chairmanships arid offices to become presi-
ent during 1973 to 1974. At present, Mrs. Gellman
erves on the Board of Governors of South Bergen
ospital as Vice-President; is a member of the National
ssoeiation of Parliamentarians; and belongs to the
alisadium Unit in Bergen County. As a member of the
ledieal Society of New Jersey Auxiliary, Grace has
?rved as liaison representative to the University of
ledicine and Dentistry of New Jersey and Volunteer
riendly Visitors; Chainnan of AMA-ERF: Recording
ecretary; Vice-President; and President-Elect.
Mrs. William B. Gellman
OL. 81— NUMBER 6— JUNE 1984
475
Golden Merit Awards
I
u
At ceremonies held on May 4, 1984, during the 218th Annual
Meeting of the Medical Society of New Jersey , Resorts
International, Atlantic City, the following received MSNJ’s Golden
Merit Award indicating they held the degree of doctor of medicine
for 50 years .
Atlantic County
Samuel M. Diskan, M.D Temple
Werner Hamburger, M.D Berlin
J. Neafie Richardson, M.D Temple
Bergen County
Roslyn Barbash, M.D Bellevue
Kalman Chase, M.D Syracuse
William D. Deuell, M.D Columbia
Joseph Greenbaum, M.D Long Island
Rev. Edmund E. Jacobitti, M.D Temple
Emil Joseph Kakascik. M.D Syracuse
Kenneth S. Landauer, M.D Johns Hopkins
Samuel N. Lipsett, M.D George Washington
Samuel G. Loman, M.D Glasgow
Edward M. Mancene, M.D New York Medical
Robert J. Neville, M.D Long Island
Nelson C. Policastro, M.D Rome
Jacob Prager, M.D Columbia
Burlington County
Maurice Lev. M.D Creighton
Paul Reed Sparks, M.D Pennsylvania
John Carl Voss, M.D Temple
Camden County
Nathan Asbell, M.D London
Francesco D’Imperio, M.D Hahnemann
Paul Mecray, Jr., M.D Pennsylvania
Edwin R Rosner, M.D Vienna
Cape May County
Jules Cooper, M.D Maryland
’34
Cumberland County
Nicholas Edward
’34
Marchione, M.D
Hahnemann ’34|
’34
Essex County
Frank G. Barnard, M.D
Hahnemann ’34
’34
Irving V. Bemey, M.D
Western Ontario ’34
’34
Bernard Bolten, M.D
St. Louis ’34
'34
Louis A Brodkin, M.D
George Washington ’34
'34
Richard H. Bruning, M.D
Columbia ’34
’34
Alton E. Bythewood, M.D
Meharry ’34
’34
John A DeVivo, M.D
Georgetown ’34
’34
Robert F. Dow, M.D
Georgetown ’34!
’34
Robert E. Fullilove, Jr., M.D.
Howard ’34
’34
Frank M. Galioto, M.D
.. New York Medical ’34
’34
Joseph Gamba M.D
St. Louis ’34
’34
E. Leslie Gaylor, M.D
Tufts ’34
’34
Jerome Gelb, M.D
Maryland ’34!
’34
Frank Giuffra M.D
Long Island ’34
Jesse T. Glazier, M.D
Hahnemann ’34
’34
Andrew J. V. Klein, M.D
Edinburgh ’34
’34
Henry H. Kosterlitz, M.D
Breslau ’22
. New York Medical ’34
’34
David B. Meisel, M.D
Irving Ocheret, M.D
George Washington ’34
’34
Patrick J. Romano, M.D
Georgetown ’34!
’34
Victor Rudomanski, M.D
Long Island ’341
’34
Thomas A Santoro, M.D
Jefferson ’34
'34
Richard H. Smith, M.D
Virginia ’34
John J. Torppey, M.D
Georgetown ’34
’34
William R Ward, M.D
Cornell ’34!
476
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
udson County
rank R Amdt, M.D New York University ’34
rban R Bigliani, M.D Loyola ’34
[ilton Blum, M.D Georgia ’34
dolph D. Casciano, M.D Columbia ’34
dlliam Feller, M.D George Washington ’34
dward D. Fenimore, M.D New York Medical ’34
ahn G. Imhoff, M.D Georgetown ’34
lement M. Jones, M.D Howard ’34
amuel Penchansky, M.D California '34
avid B. Simpson, M.D New York University ’34
[ercer County
aseph K. Bayne, M.D Hahnemann '34
[. Yale Byer, M.D Georgetown ’34
Dseph Robert Deitz, M.D Maryland '34
avid A. Fluek, M.D Hahnemann '34
vin Levy, M.D Georgetown '34
amuel Joseph Lloyd, M.D Johns Hopkins '34
idor Markowitz, M.D St. Louis ’34
auis Rampona, M.D Rush ’34
[iddlesex County
[iehael Brody, M.D Cornell ’34
vin J. Fine, M.D George Washington ’34
ollins E. Lewis, M.D Meharry '34
rilliam F. Murray, M.D Long Island '34
an B. Smith, M.D Pennsylvania ’34
idney Tucker, M.D Bellevue ’34
onmouth County
amuel Bar. M.D Jefferson ’34
avid I. Diamond, M.D George Washington ’34
jhn William Hardy, M.D Hahnemann ’34
tto Lehmann, M.D Berlin ’34
)seph F. Raffetto, M.D Georgetown ’34
orris County
Ivin A. Rosenberg, M.D. ... New York University ’34
Merlin T. Ryman, M.D Pennsylvania ’34
Ocean County
Clinton Ridgway Schneider, M.D. .. Hahnemann ’34
E. Charlotte Seasongood,
M.D Woman’s Medical ’34
Passaic County
Sidney Gelman, M.D
Harry Katz, M.D
Joseph M. Keating, M.D
Walter A. Kovaleski, M.D. ...
Morton Kulick, M.D
Stephen M. Liana M.D
William Paris, M.D
Theodore C. Sabarese, M.D.
Andrew Sporer, M.D
Leonard J. Trilling, M.D
Ralph Cady Yeaw, M.D
Maryland ’34
Rush ’34
Georgetown '34
Boston ’34
New York University '34
St. Louis ’34
Indiana ’34
St. Louis ’34
Hungary ’34
Columbia ’34
Rochester ’34
Salem County
J. Robert Cox, M.D Hahnemann ’34
Somerset County
Anthony J. Allegrante, M.D. .. New York Medical ’34
Nicholas A. Falcone, M.D Jefferson ’34
Alan J. Stolow, M.D London ’34
Union County
Herbert E. Jones, M.D Long Island ’34
Junius T. Langston, M.D Howard ’34
Evert A. Larsson, M.D Kansas ’34
James H. Maroney, M.D Columbia '34
George H. Marts, M.D Kansas ’34
William C. Meineke, M.D Hahnemann ’34
Michael Taranto, M.D Georgetown '34
John Trano, M.D Rome '34
Richard Wagner, M.D Maryland ’34
Albert I. Whitken, M.D Jefferson ’34
>L. 81— NUMBER 6— JUNE 1984
477
each day.
First-step blood pressure control
with optimal simplicity
Benefits diuretics cannot offer . . . Once-daily inderal la
(propranolol HG1) provides smooth, 24-hour control of blood pressure
plus the cardiovascular benefits of the world’s leading beta blocker.
And INDERAL LA provides a high degree of patient acceptance —
without potassium problems.
Experience no other beta blocker can match . . . Once daily
INDERAL LA delivers the proven performance and safety profile of
INDERAL tablets — confirmed by millions of patients during 16 years
of clinical use. INDERAL LA should not be used in congestive heart
failure, sinus bradycardia, heart block greater than first degree, or
bronchial asthma.
Start with 80 mg once daily. . . Dosage may be increased to
120 mg or 160 mg once daily as needed to achieve additional control.
Please see next page for further details and brief summary of
prescribing information.
i hi
80 120 160
mg mg mg
The appearance of INDERALLA capsules
is a registered trademark of Ayersl Laboratories.
Ayerst
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERALLA
(PROPRANOLOL HCI) CAPSULES
t
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately,
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it read|usts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor andjpnewhat variable. INDERAL has
been shown to cause a small increase in serum potassiJBponcentration when use'
treatment of hypertensive patients. 1|
In angina pectoris, propranolol generally reduces thjj
any given level of effort by blocking the catecholammej
systolic blood pressure, and the velocity and extent off
may increase oxygen requirements by increasing left j
pressure and systolic election period The net phy;
is usually advantageous and is manifested duriKrji®
increased work capacity.
In dosages greater than required for beta blockade, INDERAL also exerts a quinidine-l
or anesthetic-like membrane action which affects
cance of the membrane action in the treatment of
The mechanism of the antimigraine effect of prj
adrenergic receptors have been demonstrated in
Beta receptor blockade can be useful in con'
functional changes, sympathetic activity is detri ^ __
situations in which sympathetic stimulation is vital RT^ampiSHTi paTients'wWPrseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients sub|ect to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma, 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking there!
prior to maior surgery is controversial It should be noted, however, that the impaired ability1
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthe
and surgical procedures.
INDERAL (propranolol HCI). like other beta blockers, is a competitive inhibitor of be
receptor agonists and its effects can be reversed by administration of such agents, e
dobutamme or isoproterenol. However, such patients may be sub|ect to protracted sevj
hypotension Difficulty in starting and maintaining the heartbeat has also been reported w
beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes)
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be m<
difficult to adjust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidis!
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sympto.
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function tes
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have be
reported in which, after propranolol, the tachycardia was replaced by a severe bradycari,
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 ij
propranolol
PRECAUTIONS. General. Propranolol should be used with caution in patients with impaii,
hepatic or renal function INDERAL is not indicated for the treatment of hypertensl
emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Patiej
should be told that INDERAL may interfere with the glaucoma screening test. Withdrawal rr|
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart disea !
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as res
pine should be closely observed if INDERAL is administered The added catecholamiii
blocking action may produce an excessive reduction of resting sympathetic nervous actisj
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthostf
hypotension.
Carcinogenesis. Mutagenesis, Impairment of Fertility: Long-term studies in animals ha
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studies
^50 mg/kg/day, there was no evidence of signified
lated tumorigemc effects at any of the dosal
not show any impairment of fertility that vJ
be used during
Nursmq
DER," ~
4DERAL has been shown to be embryotoxic
* r than the maximum recommended human do
Tolled studies in pregnant women INDERAL shor
gnancy only if the potential benefit justifies the potential risk to the fet:
INDERAL is excreted in human milk Caution should be exercised wh
s in children have not been established,
e effects have been mild and transient and hs;
nsiol
aynau
Central Nervous Systei
lassitude, weakness, fatigu
ive heart failure; intensification of AV block, hyp
JHiflRirpura; arterial insufficiency, usually of i
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
eadedness; mental depression manifested by insomq
rsible mental depression progressing to catatonia; vis
disturbances, hallucinations; an acute reversible syndrome characterized by disorientation
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, ai
decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhi
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with ach4:
and sore throat, laryngospasm and respiratory distress
Respiratory bronchospasm.
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopeu
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has bell
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imij
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reactic ; ■
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practo p
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride i
sustained-release capsule for administration once daily. If patients are switched from INDER;
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeu
effect is maintained. INDERAL LA should not be considered a simple mg for mg substitute, ,
INDERAL INDERAL LA has different kinetics and produces lower blood levels. Retitration nr! |
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interxl
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may
increased to 120 mg once daily or higher until adequate blood-pressure control is achievi
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of 6‘
mg may be required The time needed for full hypertensive response to a given dosage
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL
once daily, dosage should be gradually increased at three to seven day intervals until optim
response is obtained. Although individual patients may respond at any dosage level, j
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the value a
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few wer
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL
once daily The usual effective dose range is 160-240 mg once daily The dosage may :
increased gradually to achieve optimum migraine prophylaxis If a satisfactory response is
obtained within four to six weeks after reaching the maximum dose, INDERAL LA ther;
should be discontinued It may be advisable to withdraw the drug gradually over a perioc.
S0V0T3I w6©Ks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group are
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratori
8950/2
Nonaliergic Bronchospasm (e.g,, chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
480
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Cardiac Amyloidosis And Idiopathic
Hypertrophic Subaortic Stenosis
Richard A. Daniels, m.d., Ronald Weinberg, m.d., Anis F. Ran gw ala m.d.,
Gary Mintz, m.d., long branch*
Our patient with hypertrophic subaortic stenosis and multiple
myeloma developed chest pain, pulmonary edema , and syncope.
Postmortem examination revealed cardiac amyloidosis with
involvement of coronary microvasculature and hypertrophic
subaortic stenosis. Abnormal hemodynamics of these diseases
were complementary and clinically fatal.
j
lit
ur understanding of recent
■ ■ therapeutic advances in the
treatment of idiopathic hyper-
ophic subaortic stenosis greatly has improved the
orbidity and perhaps decreased the mortality of this
j sease. Described anatomically in 1958 by Teare,1 the
i ndition has been known in Britain as hypertrophic
instructive cardiomyopathy and in Canada as
luscular subaortic stenosis.2
We present a man who had idiopathic hypertrophic
i baortic stenosis, multiple myeloma and cardiac
i ayloidosis. We believe the abnormal hemodynamics
i each of these diseases was additive and resulted in
i poor prognosis.
i fSE REPORT
In February 1980, our patient, a 47-year-old male,
implained of typical angina pectoris. On physical
lamination, the carotid upstroke was noted to be
fljisk bilaterally; no bruits were audible. No jugular
Inous distension was noted. The first and second
fart sounds were normal and a 2/6 systolic murmur
t the apex increased with standing and during the
tain phase of the Valsalva maneuver. Lung fields
"re clear and there was no pedal edema.
Electrocardiogram was normal. A real-time, two-
<!nensional echocardiogram (Figure 1) revealed Io-
dized hypertrophy of the proximal septum, vigorous
'all motion with systolic cavity obliteration, and left
atrial enlargement. There was no evidence of systolic
anterior motion of the mitral valve at rest. A
technetium gated scan with exercise demonstrated
normal wall motion and an ejection fraction of 62 per-
cent. A diagnosis of idiopathic hypertrophic subaortic
stenosis was made and propranolol was prescribed
with major symptomatic improvement. In April 1981,
recurrent chest discomfort prompted a thallium-201
exercise test. This demonstrated a perfusion defect at
the height of exercise in the interventricular septal
area; the defect normalized at rest.
Cardiac catheterization was performed while the pa-
tient was taking 160 mg per day of propranolol. The
left ventricle was entered via the transatrial septal
technique. Using equisensitive transducers and simul-
taneous left ventricular and aortic pressures, there was
no resting gradient. During isoproterenol infusion, the
heart rate rose from 60 to 110 per minute, and a 54
mm/Hg gradient was observed after a premature ven-
tricular contraction.
Coronary angiography revealed normal coronary ar-
teries. The left ventriculogram demonstrated vigorous
contraction with nonual cavity size. An incidental
*From the Departments of Medicine and Pathology. Mon-
mouth Medical Center, Long Branch, and the Likoff
Cardiovascular Institute, Hahnemann Medical College and
Hospital, Philadelphia. Correspondence may be addressed to
Dr. Daniels, Monmouth Medical Center. Long Branch, NJ
07740.
81— NUMBER 6— JUNE 1984
481
M4*SE
fc -WW
Figure 1 — Real-time, two-dimensional echocardiogram
(apical four-chamber view) showing hypertrophied inter-
ventricular septum. LA = left atrium: LV = left ventricle: RA
= right atrium; RV = right ventricle.
serum hyperproteinemia was noted and further evalu-
ation revealed an IgA lambda paraprotein with
supression of IgM on immunoassay. Bone marrow
aspiration revealed increased plasma cells (15 percent)
with immature binueleated cells present. A diagnosis
of multiple myeloma was made. There were no clinical
manifestations of extraeardiac amyloidosis.
The patient was hospitalized in December 1981 and
January 1982 for pulmonary edema and chest pain; he
was treated with furosemide and propranolol with
good response each time. Electrocardiogram at that
time demonstrated normal sinus rhythm at a rate of
82 beats per minute with left axis deviation and Q
waves in III, AVF, VI -V3. Nonspecific ST and T wave
changes were present. CPK-MB fractions were normal.
He was discharged and advised to take propranolol 80
mg daily and furosemide 80 mg daily.
In February 1982. the patient came to the emergency
room after a syncopal episode and complained of
severe substemal chest pain and shortness of breath.
He was in cardiogenic shock and pulmonary edema.
His electrocardiogram revealed an intraventricular
conduction defect of the left bundle-branch block type
with nonspecific ST and T wave abnormalities.
Resuscitative measures including intubation, in-
travenous fluids, and vasopressors (dopamine and nor-
epinephrine) failed to help and the patient expired in
electrical-mechanical dissociation.
POSTMORTEM RESULTS
Postmortem examination revealed a heart weight of
550 gm and a disproportionate increased thickness of
the interventricular septum (maximum thickness 2.2
cm) as compared to the posterior wall. Histological
examination showed muscle fiber hypertrophy, focal
interstitial fibrosis, cytoplasmic vacuolar degeneration
of muscle cells (Figure 2), and bizarre muscle nuclei.
Despite the absence of evidence of abnormal or
whorled arrangement of muscle fibers, these changes
are consistent with hypertrophic cardiomyopathy.
There was no evidence of acute myocardial infarction.
In multiple areas, small interstitial arteries and arteri-
oles show homogeneous deposits in their walls which
stained positively for amyloid (Figure 3). A few minute
Figure 2 — Section from the heart showing cytoplasmic vaci
lar ( | ) degeneration and hypertrophy of muscle ee,
(hematoxylin-eosin stain X 50).
f
* *
*< *
t
i
i
• t
" * v
*
Figure 3 — Section from heart showing homogenous depos: «
in the wall of the interstitial arteries which stained 1
amyloid (eongo red stain X 50).
interstitial deposits of amyloid also were present extr,
vaseularly in the epicardium and the subendocardiur!
Myeloma cells were not seen in any of the numeral:
sections of the heart. The right and the left corona1
arteries showed minimal arteriosclerosis.
Outside of the heart, there was evidence of residu
multiple myeloma involving the left fourth and eight; ^
ribs and multiple vertebral bodies. Finally, foe
amyloid was present in the bone marrow and alt;
involved the microvasculature of the lungs, stomac
urinary bladder, and periadrenal connective tissue.;
Acute massive pulmonary edema was the immediaj
cause of death.
DISCUSSION
The association of amyloidosis with multip’
myeloma was first reported by Hildebrand in 189
More recently, studies have confirmed that prima
amyloid fibrils frequently are derived from lambc
light chains of immunoglobulins.3 The mean age (
patients with multiple myeloma associated wit
cardiac amyloidosis is 60 years old.4 The medi£(
survival after diagnosis is 20 months with the usu
survival after histologic diagnosis of cardiac amylo
of 2 to 4 months.
The presenting manifestation of cardiac amyloidosj
is congestive heart failure, although ischemic hea
disease from amyloidosis of intramyocardial arterf
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
482
as been reported and may cause angina pectoris and
itraetable congestive heart failure. Cardiac ar-
lythmias, both ventricular and supraventricular, are
)mmon particularly in patients taking digitalis,
inus node infiltration resulting in supraventricular
-rhythmias explains the heightened sensitivity to
igitalis.
The modalities which strongly suggest the diagnosis
cardiac amyloidosis include M-mode and two-
imensional echocardiography, electrocardiography,
)ronaiy angiography, and ventriculography. En-
Dmyoeardial biopsy may confirm the diagnosis.
Echoeardiographic criteria include symmetrical in-
rease of left ventricular wall and septal thickness,
minished or absent systolic movement of both the
‘ptum and left ventricular wall, and diminished left
mtricular contraction resulting in generalized
/pokinesia and reduced cardiac output. The use of
/o-dimensional echocardiography has demonstrated
lickened cardiac walls with a “granular sparkling”
rpearance and may be virtually diagnostic. Quan-
tative M-mode echocardiography may reveal charac-
ristic findings among which are normal left ven-
icular cavity size, decreased peak rate of diastolic
ivity filling and prolongation of isovolumetric con-
action. The data indicate that cardiac amyloidosis is
anifest initially as diastolic dysfunction.5 Echo-
irdiographic muscle cross-sectional area tends to be
creased and there is an inverse correlation between
' sctrocardiographic voltage and muscle cross-sec-
Dnal area.6
On electrocardiogram, voltage in the precordial leads
ave in V5 and V6 usually is less than 15 mm.
:JA low cardiac index and marked elevation of the
ght and left atrial, and right and left ventricular end
astolic pressures are all encountered in cardiac
• nyloidosis.
Death in cardiac amyloidosis may be due to intrac-
ble congestive heart failure. Thirty percent of pa-
ints with primary amyloidosis died suddenly,
jesumably of a cardiac arrhythmia.7 The elee-
'bcardiogram in many of these patients revealed con-
uction defects or a spurious “myocardial infarction"
jittem. The chest pain most likely is due to amyloid
filtration of the small intramyocardial arteries,
kich are too small to be visualized by angiography.
There is no therapy at present for cardiac
• nyloidosis, except to control the abnormal plasma cell
mne which produces the light chain protein respon-
se for the amyloid fibril deposition.
The importance of percutaneous endomyocardial
topsy is clear because of its relative ease and safe-
89 as well as its role in discriminating between
• nyloidosis and other forms of restrictive heart dis-
< se.10
Hypertrophic subaortic stenosis is manifested
lithologically by asymmetric hypertrophy of the inter-
ntricular septum. Histologically, disordered arrange-
ments of septal myofibrils account for the inter-
’ ntricular septal hypertrophy. Typical hemodynamic
Ijidings are reduced left ventricular compliance and
dynamic left ventricular outflow tract gradient.
The relative compensation of the patient prior to the
iset of cardiac amyloidosis is of note in the case
L. 81— NUMBER 6— JUNE 1984
presented. As in most cases of hypertrophic
cardiomyopathy, his systolic ventricular function was
excellent as manifested by a high ejection fraction and
vigorous left ventricular contraction with normal cavi-
ty size on ventriculography. In this disease, abnormal
diastolic function is the rule with diastolic stiffness of
the ventricle causing poor early diastolic filling. The
ventricle may not be relaxed enough to accept the re-
turn from the pulmonary veins during diastole caus-
ing a rise in pulmonary pressure and pulmonary
edema even through the vigor of contraction is excel-
lent. Syncope may occur during volume depletion.
The mainstay of therapy in idiopathic hypertrophic
subaortic stenosis is beta blockade. This may be useful
in reducing chest pain, palpitations, and possible syn-
cope.11 More recent studies have shown that verapamil
can reduce left ventricular outflow obstruction,12 13 in-
crease exercise capacity,14 and reduce symptoms.15
However, verapamil has been reported to cause
pulmonary congestion and must be used with cau-
tion.16
Our patient had idiopathic
hypertrophic stenosis,
multiple myeloma, and
cardiac amyloidosis .
In our patient, we deemed it wise to avoid verapamil
because of the repeated episodes of pulmonary edema
Current opinion is that if a patient has a history of
pulmonary congestion or if the pulmonary artery
wedge pressure is above 20 mm/Hg, verapamil should
be used only if the other measures are not considered
possible.17
This patient’s terminal event was cardiogenic shock
with congestive heart failure. When he was treated
with conventional therapy for cardiogenic shock, he
failed to improve. We speculate that recurrent
pulmonary edema and death was due to the deleteri-
ous additive effect of both diseases on diastolic com-
pliance.
Cardiac amyloid usually causes poor left ventricular
systolic function. However, our patient had good left
ventricular systolic function and could manifest an
outflow gradient even while taking propranolol. There-
fore, the diagnosis of a second infiltrative myopathy
never was considered. Both hypertrophic cardio-
myopathy and cardiac amyloid cause marked reduc-
tion in diastolic compliance.
We propose that the amyloidosis in the walls of mul-
tiple interstitial arteries and arterioles and the few
interstitial deposits of amyloidosis, superimposed
upon the marked reduction of left ventricular com-
pliance of hypertrophic cardiomyopathy, led to the de-
velopment of recurrent pulmonary edema and death.
The abnormal hemodynamics of each disease ap-
peared to be complementary causing a fatal outcome.
REFERENCES
1. Teare RD: Asymmetrical hypertrophy of the heart. Br
Heart J 20:1-18, 1958.
483
2. Perloff JK: Pathogenesis of hypertrophic
cardiomyopathy: Hypotheses and speculations. Am Heart J
101:219-226. 1981.
3. Paredes JM, Mitchell BS: Multiple myeloma; Current
concepts in diagnosis and management. Med Clin North Am
64:729-742. 1980.
4. Kyle RA. Bayrd ED: Amyloidosis: Review of 236 cases.
Medicine 54:27 1 -300. 1975.
5. St. John Sutton MG, Reichek N. Kastor JA. Giuliani ER
Computerized M-mode echocardiographic analysis of left ven-
tricular dysfunction in cardiac amyloid. Circulation
66:790-799. 1982.
6. Carroll JD, Gaasch WH. McAdam KPWJ: Amyloid
cardiomyopathy: Characterization by a distinctive volt-
age/mass relation. Am J Cardiol 49:9-13. 1982.
7. Wright JR Calkins E: Clinical-pathological differentia-
tion of common amyloid syndromes. Medicine 60:429-448.
1981.
8. Brooksby LAB, Jenkins BS. Coltart DJ. Webb-Peploe MM.
Davies MJ: Left ventricular endomyocardial biopsy. Lancet
2:1222-1225. 1974.
9. Brooksby 1AB. Coltart DJ, Webb-Peploe MM: Progress in
endomyocardial biopsy. Mod Concepts Cardiovasc Dis
44:65-69. 1975.
10. Bharati S. Lev M. Denes P. Modlinger J. Wyndham C.
Bauemfeind R Greenblatt M, Rosen R Infiltrativt
cardiomyopathy with conduction disease and ventricular arj
rhythmia: Electrophysiologic and pathologic correlations. An'
J Cardiol 45:163-173. 1980.
1 1. Cohen LS. Baunwald E: Amelioration of angina pec
toris in idiopathic hypertrophic subaortic stenosis with beta
adrenergic blockade. Circulation 35:847-851. 1967.
12. Rosing DR Kent KM, Borer JS, Seides SF. Maron EL
Epstein SE: Verapamil therapy: A new approach to the phai
macologic treatment of hypertrophic cardiomyopathy:
Hemodynamic effects. Circulation 60:1201-1207, 1979.
13. Kaltenbach M. Hopf R Kober G. Bussman WD. Kelle
M. Peterson Y: Treatment of hypertrophic obstructiv
cardiomyopathy with verapamil. Br Heart J 42:35-42. 1979
14. Rosing DR Kent KM. Maron E3J. Epstein SE: Verapam
therapy: A new approach to the pharmacologic treatment c!
hypertrophic cardiomyopathy. II. Effects on exercise capacit
and symptomatic status. Circulation 60:1208-1213. 1979
15. Rosing DR Condit J. Maron GJ. Kent KM. Leon MC
Banow RO. Lipson LC. Epstein SE: Verapmil therapy: A ne\
approach to the pharmacologic treatment of hvpertrophi
cardiomyopathy. Am J Cardiol 48:545-553, 1981.
16. Epstein SE. Rosing DR. Verapamil: Its potential fcl
causing serious complications in patients with hvpertrophi'
cardiomyopathy. Circulation 64:437-441. 1981.
t
(
484
i
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW
'
jerse;
Medical Society of New Jersey Sponsors
i.C. System Debt Collection Service
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EFFECTIVE COLLECTORS
PROVIDE FINANCIAL ADVICE
They are counselors, financial advisors, and often, un-
derstanding friends. They are cursed at, lied to, and
thanked. They are I.C. System’s telephone collectors. If
the image you have of a collector is a burly six-foot hulk,
then you are in for a surprise. Perci Berry is no hulk. Yet
this five-foot three-inch woman has collected thousands
of dollars for clients of I.C. System. “We distinguish
ourselves from the strong-arm impression of collection
agencies of years past,” she said in a recent interview.
“We take pride in our effective technique of collec-
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ing a counselor to a debtor, working together to resolve a
financial problem. “We say to debtors, ‘We need your
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so to speak, we become the person who is going to help
them clear up a problem,” she said. “We are counsel-
ors.” As counselors, Perci and her co-workers provide
debtors with financial advice. After two years as a col-
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have assets they are not even aware of that they can
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ide ideas to help debtors through their financial trou-
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put a bill aside because it has been outstanding for so
long they feel it can go a little longer,” Kim said. “Or
they feel since it’s not the car or mortgage payment,
can wait.” She added, “We point out to them that it
important.” “I stress to debtors that they have a mo
obligation to pay,” Kim continued. “I tell them tl .
person trusted you by extending credit, now you have
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collectors find a debtor is simply not able to pay, “K
said, “I try to set up a payment plan that will not invol
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plained that although the dispute may have some mei
the debtor must do more than just ignore the bill. “Ci
tomers have an obligation to register a dispute — to
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back. Go back to where you bought it and tell the
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it is important to give the creditor an opportunity to ma
a satisfactory settlement. “Most creditors, most bus
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ing complaints, whether it’s a partial refund or doing t
work over again,” Julia said. Working together, ti
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I
I.C. SYSTEM, INC.
444 East Highway 96
P. 0. Box 64639
St. Paul, Minnesota 55164
rHE SMOKING CESSATION
DEDUCTION ACTION PROGRAM
Norman Hymowitz, ph.d., Idamarie Laquatra, Sarah Karl, Newark*
Programs to help adults stop smoking have beenfrustrated by
high rates of relapse. Long-term clinical trials for disease
prevention yield better abstinence rates. SCRAP , a worksite-
based program, will determine whether effective features from
clinical trials can be implemented to produce comparable
abstinence rates.
The issues of cigarette smoking
and its modification pose im-
portant challenges to pro-
ssionals in public health and behavioral medicine,
le 1979 report of the Surgeon General documents
e significant health hazards of cigarette smoking.1
;spite the vast array of health statistics contained in
e report, millions of adults continue to smoke and
iung people are acquiring the smoking habit at an
arming rate.2 While antismoking activities have con-
ibuted to a decline in adult smoking rates3 and a
•crease in the per capita consumption of cigarettes,4
‘havioral intervention programs specifically designed
help adults stop smoking have met with limited
iccess. Many stop-smoking programs yield eom-
irable satisfactory end-of-treatment quit-rates (i.e. 40
60 percent), but few have succeeded in maintaining
msmoking behavior over time.58 Hunt and Bespalec
ported that 70 to 80 percent of successful graduates
stop-smoking programs relapse within one year fol-
ding the end of treatment.9 While aversive tech-
ques tend to produce somewhat better quit-rates,10
lapse remains a problem,11 and their utility from a
rblic health viewpoint is limited by potentially
rious adverse side effects.12
Findings from recently completed prospective
meal trials for the prevention of heart disease yield
ng-term quit-rates which exceed those typically re-
nted in the smoking modification literature.13 16 After
six years of followup in the Multiple Risk Factor Inter-
vention Trial (MRFIT), for example, close to 50 percent
of the Special Intervention (SI) group who reported
smoking at the start of the trial reported not smoking13
and 56 percent of SI participants who quit smoking
by the end of the initial ten-week group intervention
program never relapsed through the first four years of
the trial (data for six years of followup for this cohort
are not yet available).17 The reported quit-rate after five
years of the Oslo Study was 30 percent;14 for the in-
tensive intervention group in the Stanford program,
50 percent after three years;15 and for the Randomized
Trial of Antismoking Advice in London, 55 percent
after nine years of followup.16
Prospective clinical intervention trials differ in many
ways from more traditional stop-smoking programs,
which make it difficult to determine which features of
the trials account for the higher long-term abstinence
rates. The focus of clinical trials is on disease preven-
tion, and cigarette smoking often is one of several risk
factors treated. Thus, it is likely that participants in
clinical trials are better able to personalize the risk
which smoking presents, to be more aware of the
potential benefits of stopping smoking, and to ap-
*From UMDNJ-New Jersey Medical School, Department of
Psychiatry and Mental Health Science. Correspondence may
be addressed to Dr. Hymowitz, UMDNJ-New Jersey Medical
School, 100 Bergen Street, Newark. NJ 07103.
OL. 81— NUMBER 6— JUNE 1984
487
preciate better the concepts of disease prevention and
health enhancement than smokers enrolled in more
traditional stop-smoking programs.
Participants in clinical trials usually undergo ex-
tensive medical screening and evaluation at the start
and during the course of the trial. It is conceivable that
the periodic followup and medical assessment con-
tribute to an overall milieu in which the effectiveness
and long-term impact of behavioral stop-smoking tech-
niques are enhanced. The reactive impact of periodic
health assessment alone on smoking cessation may be
seen best by the performance of participants assigned
to control conditions in the clinical trials. They are
examined periodically but usually do not receive advice
and assistance in discontinuance of smoking. In the
MRFIT, the Usual Care Group quit-rate increased each
year, yielding a quit-rate at year six of 29 percent. The
quit-rate for the control group in the Oslo Study in-
creased to 18 percent at year five.14 In the Paris
Cardiovascular Risk Factor Trial, the quit-rate for con-
trols at year two was 28 percent,18 and for the control
group in the Multifaetoral Prevention Trial in Gothen-
burg, Sweden, it was 26 percent after four years.19
These rates reflect the impact of consistent followup
and periodic medical evaluation.
Smaller studies which used the features of long-term
followup and medical evaluation showed long-term
nonsmoking rates comparable to the clinical trials.
Hymowitz, Lasser, and Safirstein studied the effects on
smoking cessation of a filter system for gradual smok-
ing withdrawal.20 This study emphasized the health
benefits of smoking cessation and required partici-
pants to return to the clinical center periodically for
measurement of carbon monoxide, pulmonary symp-
toms, pulmonary function, serum cholesterol, and
blood pressure. Subjects were assigned randomly to
one of three experimental conditions: quit smoking on
their own, quit smoking through the use of a placebo
filter system, or quit smoking through the use of the
real filters. No other form of assistance to cease smok-
ing or to remain abstinent was used. The initial quit-
rate at the end of eight weeks was modest, with no
differences among conditions. However, more than 50
percent of the initial quitters still were abstinent one
year later. This finding is consistent with clinical trial
data in suggesting that emphasis on health enhance-
ment, feedback about health status, and persistent
followup are important ingredients for long-term
smoking cessation.
Recent studies by Malotte, Fielding and Danaher21
and Tongas22 also demonstrate the importance of
emphasis on health enhancement and intensive fol-
lowup in more traditional undertakings. Malotte et al.
described the results of the smoking cessation compo-
nent of a 24-day residential program aimed at achiev-
ing lasting improvement in known risk factors for
heart and lung disease. Data on self-reported
abstinence revealed 72 percent of the smokers were
abstinent at discharge and 53 percent were abstinent
at six months. In one group. Tongas employed a 5-day
treatment program of aversive conditioning and covert
conditioning in combinations with intensive followup
and maintenance over a 12-month period. Self-reports
of abstinence for subjects who completed the 5-day
program in the combined treatment group revealed 77
percent abstinence at 6 months, 77 percent at i
months, and 62 percent abstinence at 24 month:
Smoking cessation and long-term abstinence ,e
complex processes which are influenced by a vari)
of factors. Psychosocial variables which predispose:
abstinence and relapse, the effectiveness of diffenjt
modes of therapy, and patients most likely to prn
from a particular approach are important topics i
future research. The clinical trial data suggest ini'-
vention strategies prove more effective when eoupri
with an overall health milieu and long-term follow)
It is of utmost importance to determine whetlr
variables which played an important role in produc a
long-term cessation results in the clinical trials can 3
incorporated in a cost-effective manner in other si
tings to enhance the impact of more traditional ste.l
smoking programs. While resources available
clinical trials are not typically available in other s||
tings, it is possible to approximate the clinical till
atmosphere in a systematic fashion. For examp,
smokers may be informed that they are taking part .
a long-term health enhancement and intervention
fort from the start, so that maintenance and follow:
become integral features of the program. Modifi:
physical examination and periodic assessment mayr
included to help smokers personalize their risk f
smoking and remain aware of the health benefits!
stopping. Such examinations should include medii
and pulmonary history to identify “high-risk smoke
and, where possible, the measurement of carbon me
oxide, coronaiy risk factors, and spirometry. Coope
tive arrangements with community health agencies :
area hospitals would enable a wide variety of smokij
cessation programs to incorporate health assessme ,
health enhancement, and regularly scheduled follow >
visits. Based on the clinical trial data, such featus
may be expected to enhance the impact of interventi i
and help create an environment conducive to lor
term maintenance of nonsmoking behavior.
Where possible, health professionals should enl;
the support of the family, the community, and tja
personnel at the worksite to enhance long-term sme
ing modification. Interventions at the worksite are a
vantageous because they afford opportunities for lj-
lowup.24 Many communities have events related to lj-
ness and health, such as stress management class,
at adult schools, weight loss and low calorie cooki ;
classes, and various health fairs and exhibits,
bringing various activities to the attention of the me: -
bers of smoking groups, incorporating attendance
these events into specific behavioral contracts, ajli
providing followup at the worksite and elsewhere,
may be possible to carry out a systematic and coi
prehensive smoking cessation and followup progrs
which leads to high rates of initial cessation as wl
as successful long-term abstinence. One should nc
that in the Stanford Heart Disease Prevention Pi
gram, the most success in smoking cessation was
those who received mass media health education coi
munications, face-to-face group intervention, and s>j
tematic followup.
SCRAP
A smoking cessation program currently underway
the New Jersey Medical School, the Smoking Cess;
488
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
m Reduction Action Program (SCRAP), is specifically
■signed to determine whether features which
oduced high long-term cessation rates in clinical
lals for disease prevention can be applied in a corn-
unity setting in a cost-effective manner to produce
mparable satisfactory long-term rates of smoking
ssation. Key features which the program borrows
Dm clinical trials are: (a) commitment of participants
a long-term evaluation of the health impact of
garette smoking and health benefits of cessation as
iposed to enrollment in a short-term stop-smoking
ogram; (b) initial assessment of cardiovascular risk
■ctors, pulmonary function, carbon monoxide ex-
osure, and medical history to help smokers per-
nalize the health risks which cigarettes present; (c)
'riodie evaluation of changes in these measures for
■leyear to document the health benefits which accrue
hen smokers stop smoking: (d) skills to stop smoking
id to remain abstinent: and (e) health education and
ganizational management activities through which
nokers may be more likely to initiate and maintain
'alth-related behaviors. (The latter health education
tivities derive from the successful experience of the
anford Three Communities Program.)
The features described are incorporated in SCRAP
rough three interacting components: (a) organiza-
: nal management (i.e. development of nonsmoking
:|licies at the worksite); (b) health education (i.e.
diovisual presentations, brochures, self-help stop-
i loking aids); and (c) an intensive group intervention
d followup program. The organizational manage-
;nt and health education components create an
jsrall milieu at the worksite within which smoking
i ssation and long-term nonsmoking maintenance are
Militated. The intensive group intervention and fol-
vup program incorporates the most advanced con-
ot in stop-smoking technology and specifically is de-
: (ned to help adult smokers stop smoking and remain
garette free.
To maximize the opportunity for followup and inter-
intion, the SCRAP will be carried out at a worksite
:ting. For the initial pilot project, seven hospitals in
idson, Essex, and Union Counties have been
ected: Bayonne Hospital, Elizabeth General Hospital,
Elizabeth Hospital, Alexian Brothers Hospital, New-
£ Beth Israel Hospital, East Orange General Hospital,
d St. Mary’s Hospital, Orange. Representatives of the
spitals were trained to carry out all components of
’RAP. Each smoking counselor conducts three
loking groups: one each in the fall, winter, and
ring. All participants will be followed for one year
lowing the end of initial group intervention, so it is
pected that the pilot phase of SCRAP will be com-
ded in the spring of 1985.
The pilot phase of SCRAP will lead to the develop-
ment of a manual for training smoking counselors, a
taual for conducting initial group intervention and
lowup, and a manual for health education and or-
nizational management (e.g. no-smoking policies,
rnges for nonsmokers, reduced insurance premiums
' nonsmokers). The Metropolitan Chapter of the
nerican Heart Association, which is sponsoring
’RAP, eventually will serve as a certifying agency for
’RAP smoking counselors; SCRAP manuals and ma-
1 ials will be available to the public for implementa-
[
tion in other settings under Heart Association super-
vision.
EVALUATION
EX/aluation of the effectiveness of SCRAP will be ac-
complished through several means. While all hospitals
will implement the SCRAP initial group intervention
and followup program, only three randomly selected
hospitals will implement the health education and or-
ganizational management components. Thus, it will be
possible to assess the effects of the health education
and organizational management component on initial
and long-term cessation by comparing changes in
smoking rates among SCRAP participants in the seven
hospitals. We expect that the hospitals receiving group
intervention plus health education and organizational
management will yield superior long-term ( 1 2 months)
quit-rates than the hospitals receiving only the group
intervention program. Carbon monoxide measure-
ments will serve as objective measures of smoking
status.23
Two smoking surveys will be conducted among em-
ployees at the seven hospitals. This will permit
assessment of smoking habits for each employee group
in the hospitals at the start and end of the program.
We anticipate that there will be significantly more
cessation and changes in smoking behavior among
employees not taking part in the SCRAP group inter-
vention program in the hospitals receiving the health
education and organizational management compo-
Seventy to SO percent of
successful graduates of
stop-smoking programs
relapse within one year
following the end of
treatment .
nents of SCRAP than in the hospitals not receiving
this aspect of the program.
Another form of evaluation will be based on feedback
from the newly trained SCRAP smoking counselors.
The SCRAP group intervention manual, for example,
contains evaluation forms to be completed after each
of the eight weekly group sessions. Smoking counse-
lors will be asked to comment on the flow and content
of the sessions, time constraints, and handouts and
audiovisual materials. They also will be asked to de-
scribe any modification they had to make when con-
ducting the sessions. Based on their input, the manual
and program will be revised. By the spring of 1985, it
will be possible to evaluate the effects of SCRAP on the
smoking behavior of hospital employees, the specific
influence of health education and organizational man-
agement, and the utility of SCRAP materials and man-
uals. At that point, a decision will be made concerning
the availability of SCRAP for implementation by other
hospitals and worksites.
SUMMARY
Cigarette smoking represents a major threat to pub-
lic health, increasing risk of premature heart attack.
)L. 81— NUMBER 6— JUNE 1984
489
cancer, and noneaneerous bronchopulmonary disease.
Efforts to help smokers stop smoking continue, with
considerable attention being directed at ways of
achieving long-term abstinence. SCRAP borrows heavi-
ly from the design and organization of long-term
clinical trials for disease prevention whose long-term
cessation rates were among the best reported to date.
Whether or not it is possible to produce similar results
in community and worksite settings, at far less cost,
remains an important empirical question. However, in
view of the growing numbers of young people who
smoke, as well as the increasing number of women
smokers, the need to explore new ways to intervene on
adult smoking behavior cannot be overemphasized.
SCRAP is a multicomponent program, featuring con-
temporary behavioral approaches to smoking cessa-
tion and long-term abstinence, health education, and
organizational management. It seeks to encourage
cessation and promote abstinence through creation of
an overall milieu in which the effectiveness of smoking
cessation strategies are enhanced. To the extent that
SCRAP is successful in demonstrating methods for
achieving long-term abstinence, the program will serve
the important role of bridging research, clinical trial
technologies, and community applications. It is hoped
that SCRAP will provide insight and guidance into
how principles and methods derived from a variety of
approaches can be pooled and synthesized to yield
more successful interventions.
ACKNOWLEDGEMENTS
This work was supported in part from grants from
the Metropolitan Chapter of the American Heart As-
sociation, Demonstration and Education Research
Grant R18HL 28910 (NIH) and postdoctoral training
grant. Behavioral Aspects of CHD Prevention T-32-
HL-07454-01A26 (NIH).
The Directors of SCRAP for each of the hospitals are
as follows: East Orange General Hospital, Ms. Mary
Jane Guensch; St. Mary’s Hospital, Ms. Regina Coyle;
Bayonne Hospital, Mr. Fred Lang; Alexian Brothers
Hospital, Ms. Susan Felski-Hessel and Ms. Ann Gold-
berg; Elizabeth General Hospital, Mr. Steve Kendall;
Newark Beth Israel Hospital, Ms. Renee Salkin; St.
Elizabeth Hospital, Mr. Michael O'Hea and Mr. Paul
Chabella.
REFERENCES
1. U.S. Public Health Service: Smoking and health: A report
to the surgeon general. DHEW Publication No. (PHS)
79-50066. Washington, D.C., U.S. Government Printing Office,
1979.
2. Hymowitz N: Teenage smoking: A medical responsibility.
Developmental Behavioral Pediatrics 1:164-172, 1980.
3. Schuman LM: Patterns of smoking behavior, in Jarvik
ME, Gritz JW, Vogt TM, West LJ (eds), Research on Srru
ing Behavior. NIDA Research Monograph Series 17. DHI
Publication No. (ADM) 78-581, 1977.
4. Warner KE: Cigarette smoking in the 1970s: The imp;
of the antismoking campaign on consumption. Scier
211:729-731, 1981.
5. Benfari RC, Ockene JK, McIntyre KM: Control of cigar!
te smoking from a psychological perspective. Annu Rev Put
Health 3:101-128, 1982.
6. Leventhal H, Cleary PP: The smoking problem: A revi
of the research and theory in behavioral risk modificati;
Psychological Bulletin 88:370-405, 1980.
7. Lichtenstein E: The smoking problem: A behavioral p
spective. J Consult Clin Psychol 50:804-819, 1982.
8. Vogt TM: Cigarette smoking: History, risks, and behav;
change. Int J Mental Health 11:6-43, 1982.
9. Hunt WA Bespalec DA An evaluation of cum
methods of modifying smoking behavior. J Clin Psycll
30:431-438, 1974.'
10. Danaher BM: Research on rapid smoking: Inter
summary and recommedations. Addictive Behavic ,
2:151-166, 1977.
11. Raw M, Russell MAH: Rapid smoking, cue exposu)
and support in the modification of smoking. Behavior I
search Therapy 18:362-373, 1980.
12. Hymowitz N: Behavioral approaches to preventi
heart disease: Risk factor modification. Int J Mental Hea
9:27-69, 1980.
13. Multiple Risk Factor Intervention Trial Group and M;
tiple Risk Factor Intervention Trial: Risk factor changes a
mortality results. JAMA 248:1465-1477, 1982.
14. Hjermann I, Holme I, Velve Byre K, Leren P: Effect
diet and smoking intervention of the incidence of corone
heart disease. Lancet 11:1303-1310, 1981.
15. Meyer AJ, Nash JD, McAlister AL, Maccoby N, Farquh
JW: Skills training in a cardiovascular health education ca
paign. J Consult Clin Psychol 48:129-142, 1980.
16. Rose G, Hamilton PJS, Calwell L, Shipley MJ: A ra
domized controlled trial of anti-smoking advice: 10-year i
suits. J Epidemiol Community Health 36:102-108, 1982
17. Hughes GH, Hymowitz N, Ockene JK, Simon N, Vc
TM: The Multiple Risk Factor Intervention Trial (MRFIT).
Intervention on smoking. Prev Med 10:476-500, 1981.
18. Cambien F, Richard JL, Ducimetiere P, Wamet J
Kahn J: The Paris Cardiovascular Risk Factor Preventi;
Trial. J Epidemiol Community Health 35:91-97, 1981.
1 9. Werko L: Prevention of heart attacks: Multifactorial pi
ventive trial in Gothenburg, Sweden. Ann Clin Res 1 1:714
1979.
20. Hymowitz N, Lasser NL, Saferstein BH: Effects of grad!
ated external filters on smoking cessation. Prev Mi
11:85-95, 1982.
21. Malotte CK, Fielding JE, Danaher BG: Description ai
evaluation of the smoking cessation component of a multipi
risk factor intervention program. Am J Public Heal\
71:844-847, 1981.
22. Tongas PN: The long-term maintenance of nonsmokif
behavior, in Jarvik ME, Cullen JW, Gritz ER, Vogt TM, We.
LJ (eds). Research on Smoking Behavior. NIDA Reseani
Mongraph Series 17. DHEW Publication No. (ADM) 78-56
1977.
23. Hymowitz N: Personalizing the risk of cigarette smo;<
ing. J Med Soc NJ 77:579-582, 1980.
24. Orleans CS, Shipley RH: Worksite smoking cessatiq
initiatives: Review and recommendations. Addictive Beha
iors 7:1-16, 1982.
490
VOL. 81— NUMBER 6— JUNE 198
rangymi the brown pharmaceutical co., inc.
2500 West Sixth Street, Los Angeles, CA 90057
For Full Prescribing Information, Please See PDR.
REFER TO
PDR
Android 5; 10 25
Methyltestosterone US.R Tablets
Androidvf
Fluoxymesterone U.S.R Tablets, 10
An added complication...
in the treatment of bacterial bronchitis*
Brief Summary. Consult the package literature for prescribing
intormatlon.
Indications and Usage: Ceclor® (cefaclor. Lilly) is indicated in the
treatment of the following infections when caused by susceptible
strains ol the designated microorganisms
Lower respiratory intections, including pneumonia caused by
Streptococcus pneumoniae (Diplococcus pneumoniae), Haemophilus
influenzae, andS pyogenes (group A beta-hemolytic streptococci)
Appropriate culture and susceptibility studies should be performed
to determine susceptibility of the causative organism to Ceclor
Contraindication: Ceclor is contraindicated in patients with known
allergy to the cephalosporin group of antibiotics
Warnings: IN PENICILLIN-SENSITIVE PATIENTS, CEPHALOSPORIN
ANTIBIOTICS SHOULO BE ADMINISTERED CAUTIOUSLY. THERE IS
CLINICAL AND LABORATORY EVIDENCE OF PARTIAL CROSS-
ALLERGENICITY OF THE PENICILLINS AND THE CEPHALOSPORINS
AND THERE ARE INSTANCES IN WHICH PATIENTS HAVE HAD
REACTIONS, INCLUDING ANAPHYLAXIS, TO BOTH DRUG
CLASSES
Antibiotics, including Ceclor, should be administered cautiously to
any patient who has demonstrated some form of allergy, particularly
to drugs
Pseudomembranous colitis has been reported with virtually all
broad-spectrum antibiotics (including macrolides, semisynthetic
penicillins, and cephalosporins); therefore, it is important to consider
its diagnosis in patients who develop diarrhea in association with the
use of antibiotics Such colitis may range in severity from mild to
life-threatening
Treatment with broad-spectrum antibiotics alters the normal flora
of the colon and may permit overgrowth of Clostridia Studies
indicate that a toxin produced by Clostridium difficile is one primary
cause of antibiotic-associated colitis.
Mild cases of pseudomembranous colitis usually respond to drug
discontinuance alone In moderate to severe cases, management
should include sigmoidoscopy, appropriate bacteriologic studies, and
fluid, electrolyte, and protein supplementation. When the colitis does
not improve after the drug has been discontinued, or when it is
severe, oral vancomycin is the drug of choice for antibiotic-
associated pseudomembranous colitis produced by C difficile Other
causes of colitis should be ruled out
Precautions: General Precautions— If an allergic reaction to Ceclor
occurs, the drug should be discontinued, and, if necessary, the
patient should be treated with appropriate agents, eg, pressor
amines, antihistamines, or corticosteroids
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms Careful observation of the patient is
essential If superinfection occurs during therapy, appropriate
measures should betaken
Positive direct Coombs' tests have been reported during treatment
with the cephalosporin antibiotics. In hematologic studies or in
transfusion cross-matching procedures when antiglobulin tests are
performed on the minor side or in Coombs' testing of newborns
whose mothers have received cephalosporin antibiotics before
parturition, it should be recognized that a positive Coombs' test may
be due to the drug.
Ceclor should be administered with caution in the presence of
markedly impaired renal function. Linder such conditions, careful
clinical observation and laboratory studies should be made because
safe dosage may be lower than that usually recommended
As a result of administration of Ceclor, a false-positive reaction for
glucose in the urine may occur. This has been observed with
Benedict's and Fehling's solutions and also with Clinitest® tablets but
not with Tes-Tape® (Glucose Enzymatic Test Strip, USP, Lilly)
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history of gastrointestinal disease, particularly
colitis.
Usage in Pregnancy— Pregnancy Category B— Reproduction
studies have been performed in mice and rats at doses up to 12 times
the human dose and in ferrets given three times the maximum human
dose and have revealed no evidence of impaired fertility or harm to
the fetus due to Ceclor. There are, however, no adequate and
well-controlled studies in pregnant women Because animal
reproduction studies are not always predictive of human response,
this drug should be used during pregnancy only if clearly needed
Nursing Mothers— Small amounts of Ceclor have been detected in
mother's milk following administration of single 500-mg doses
Average levels were 0 18. 0.20. 0 21 , and 0 16 mcg/ml at two, three,
four, and five hours respectively. Trace amounts were detected at one
Some ampiclllin-resistant strains of
Haemophilus influenzae— a recognized
complication of bacterial bronchitis*— are
sensitive to treatment with Ceclor.1 6
In clinical trials, patients with bacterial bronchitis
due to susceptible strains of Streptococcus
pneumoniae, H. influenzae, S. pyogenes
(group A beta-hemolytic streptococci), or multiple
organisms achieved a satisfactory clinical
response with Ceclor.7
Cefaclor
Pulvules®, 250 and 500 mg
hour. The effect on nursing infants is not known. Caution should be
exercised when Ceclor' (cefaclor, Lilly) is administered to a nursing
woman
Usage in Children— Safety and effectiveness of this product for use
m infants less than one month of age have not been established
Adverse Reactions: Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2.5 percent of patients
and include diarrhea (1 in 70).
Symptoms of pseudomembranous colitis may appear either during
or after antibiotic treatment. Nausea and vomiting have been reported
rarely
Hypersensitivity reactions have been reported in about 1.5 percent
of patients and include morbilliform eruptions (1 in 100). Pruritus,
urticaria, and positive Coombs' tests each occur in less than 1 in 200
patients. Cases of serum-sickness-like reactions (erythema
multilorme or the above skin manifestations accompanied by
arthritis/arthralgia and, frequently, fever) have been reported These
reactions are apparently due to hypersensitivity and have usually
occurred during or following a second course of therapy with Ceclor
Such reactions have been reported more frequently in children than in
adults Signs and symptoms usually occur a fevfdays after initiation
of therapy and subside within a few days after cessation of therapy
No serious sequelae have been reported Antihistamines and
corticosteroids appear to enhance resolution of the syndrome
Cases of anaphylaxis have been reported, half of which have
occurred in patients with a history of penicillin allergy
Other effects considered related to therapy included eosinophilia
( 1 in 50 patients) and genital pruritus or vaginitis (less than 1 in 100
patients)
Causal Relationship Uncertain— Transitory abnormalities in clinical
laboratory test results have been reported. Although they were of
uncertain etiology, they are listed below to serve as alerting
information for the physician
Hepatic — Slight elevations of SCOT. SGPT, or alkaline phosphatase
values (1 in 40)
Hematopoietic— Transient fluctuations in leukocyte count,
predominantly lymphocytosis occurring in infants and young children
(1 in 40)
Renal— Slight elevations in BUN or serum creatinine (less than 1 in
500) or abnormal urinalysis (less than 1 in 200)
I061782R)
* Many authorities attribute acute infectious exacerbation of chronic
bronchitis to either S. pneumoniae or H influenzae *
Note Ceclor is contraindicated in patients with known allergy to the
cephalosporins and should be given cautiously to penicillin-allergic
patients.
Penicillin is the usual drug of choice in the treatment and
prevention of streptococcal infections, including the prophylaxis of
rheumatic fever See prescribing information
References
1 Antimicrob Agents Chemother . 8:91 . 1975.
2 Antimicrob Agents Chemother , 7 7 .470. 1977
3 Antimicrob Agents Chemother , 13 584, 1978
4 Antimicrob Agents Chemother , 72 490, 1977
5 Current Chemotherapy (edited by W. Siegenthaler and R Luthy),
11880 Washington, D C American Society for Microbiology.
1978.
6 Antimicrob Agents Chemother , 73. 861, 1978
7. Oata on file, Eli Lilly and Company.
8 Principles and Practice of Infectious Diseases (edited by G L
Mandell. R G Douglas. Jr , and J.E Bennett), p 487 New York:
John Wiley & Sons, 1979
© 1982, ELI LILLY AND COMPANY
Additional information available to
the profession on request from
Eli Lilly and Company.
Indianapolis, Indiana 46285
Eli Lilly Industries. Inc.
Carolina, Puerto Rico 00630
M
\\
492
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
Promoting Compliance in
Hypertensive Patients
Phyllis Supino, ed.d., Audrey R. Gotsch, ph.d., David Van Harlingen, ed.d.,
Judy Hebble, piscataway*
A survey was conducted to obtain information about strategies used
by New Jersey private practitioners to promote compliance in
hypertensive patients . Findings revealed that while patient
noncompliance was of universal concern , attempts to counter it were
limited , variable , and related to physician profile characteristics .
The control of hypertension has
received significant attention in
the literature due to the per-
/asive nature of this disease entity, its potentially life-
hreatening nature, and the difficulties associated
ivith treatment. Although research has demonstrated
(hat medication can reduce blood pressure and the
oneomitant incidence of coronary artery disease and
hronic renal failure,1 the effective management of hy-
)ertension often is compromised by patient non-
tdherence to the prescribed treatment regimen and
Jhe practitioner’s understanding of this phenome-
ion.2 4 The problem of noneomplianee for hypertensive
>atients arises for three major reasons: the
Asymptomatic nature of this condition, the prolonged
reatment period, and the potentially adverse effects of
nedications.5
A recent study by Haynes, Mattson, and Engle-
iretson reported that health care professionals have
>een using a variety of strategies in different delivery
■ettings which have the potential to promote eom-
>lianee and allow for more patient involvement and
esponsibility in long-term therapy maintenance.6
lowever, these authors identified a gap in the available
nformation regarding the private practitioners' prep-
aration for and efforts to address this problem which,
hey concluded, might be due to the low incidence of
ormal reporting by this group. Recognizing the need
or such data from private physicians, the Office of
I
Consumer Health Education, Department of En-
vironmental and Community Medicine, UMDNJ-
Rutgers Medical School, surveyed private practice
physicians in New Jersey.
Hypertension was chosen as the subject of the study
because it ranks among the conditions for which com-
pliance problems are most critical. The purposes of the
survey were: (a) to determine for this population the
nature and extent of previous educational preparation
in the broad area of patient management techniques,
(b) to evaluate the nature and scope of strategies used
by these physicians to promote medication compliance
in hypertensive patients, and (c) to assess the rela-
tionship between physician profile characteristics and
use of compliance-promoting strategies.
METHODOLOGY
During the spring of 1981, the UMDNJ-Offiee of Con-
sumer Health Education developed and mailed survey
forms to a random sample (n= 1,309) of New Jersey
private practice physicians, representing the primary
care specialties of internal medicine, general practice,
and family practice. The form consisted of two sections
containing predominately closed-ended. multiple-
*From the Office of Consumer Health Education. UMDNJ-
Rutgers Medical School. Correspondence may be addressed
to Dr. Supino, UMDNJ-Rutgers Medical School. University
Heights, Piscataway, NJ 08854.
i/OL. 81— NUMBER 6— JUNE 1984
493
TABLE 1
Percentage of Respondents Using Compliance-Promoting Strategies Differing Significantly on a Chi-Square Test
By Age, Date of Graduation and/or Number of Years in Present Practice
Strategy Age
Under
Over
X2
36
36-47
48-57
58-67
67
(df=4)
Telephone reminders
—
—
—
—
—
—
Mail reminders
39
24
6
1 1
8
16.75+
Self monitoring
—
—
—
—
—
—
Nonphysieian
counseling
44
44
24
9
10
19.59+
Strategy
Medical
School
Graduation Date
Number of Years in Present Practice
P re-
1940
- 1950-
1960
1970-
X2
Under
Over
X2
1940
1949
1959
1969
1979
(df=4)
10
10-19 20-29
30-39 40
(df=4)
Telephone reminders
29
25
30
27
55
10.17*
—
—
—
— —
—
Mail reminders
7
13
10
26
34
12.07*
30
20
7
13 5
10.95*
Self-monitoring
42
52
57
84
71
12.24*
75
71
52
54 38
10.87*
Nonphysieian
counseling
4
13
26
40
49
20.42+
42
35
27
1 1 6
14.60+
*P<. 05
+PC.01
Note: Data for nonsignificant differences have been omitted.
choice items. The first section, “General Information,"
collected data on selected demographic characteristics
of the respondents, characteristics of their medical
education, nature of current practice and specialty
area, and amount of time spent with patients during
an average office visit. The second section, "Hyper-
tensives and Compliance Strategies," contained ques-
tions that measured the percent of patients being
treated for a hypertensive condition, perceived levels of
compliance among these hypertensive patients, and
attitudes toward the noncompliant patient. In ad-
dition, this section assessed the nature of organiza-
tional, behavioral, and educational strategies used to
foster compliance.
RESULTS
Two hundred sixty three physicians responded; of
these, 209 (79.5 percent) returned completed fonns
within the given time period and their responses form
the basis of this report. All data were analyzed to de
termine the frequency of responses to each of the vari
ous questions on the survey form and all frequencies
were converted to percentages of the total response for
that item. Chi-square tests were conducted to de-
termine the relationship between respondent profile
characteristics and implementation of individual com-
pliance strategies. In addition, analysis of variance was
used to examine the effects of these profile charac-
teristics on the number of compliance strategies re-
ported.
Because followup of nonrespondents was not possi-
ble within the design and budget constraints of this
study, representativeness of response reported by the
population surveyed was examined through eoi!
parisons with data obtained from respondents wj
had returned completed survey forms between two aj
ten months late (n = 54). This technique, described
the literature as an alternative to traditional followij
strategies,7 is predicated upon findings of similarity :
response between very late responders and nonrespo!
dents. These comparisons revealed no significant dj
ferences between early and late respondents on ail
profile characteristic except that the latter group ij
ported more training during residency in intf
personal skills (x2 = 5.48, df-1, P<.05), patient educi
tion (x2 = 5.51, df=l, P<.05), and patient trackii
procedures (x2 = 4.33, df=l, P<.05). No other educj
tional differences were found between the two grou
of respondents. Moreover, both early and late respo
dents were similar with respect to number of sche
uled office hours, time spent per patient visit, numb
of hypertensive patients seen, techniques used i
assess noneompliance, and attitudes toward and t
haviors directed at noncompliant patients (includii;
the nature of compliance-promoting strategies user
Respondents predominantly were male (95 pereef
and ranged from 27 to 81 years of age with a medi;
age of 52 years. Twenty-one percent graduated fro
medical school prior to 1940, 19 percent in the 194C
22 percent in the 1950s, 14 percent in the 1960s, ai
24 percent in the 1970s. The distribution of numb
of years in practice was consistent with the date
graduation. Of those responding, 7 percent receiv<;{
their medical degrees from New Jersey schools, 68 pe
cent from states other than New Jersey, and the r
maining 25 percent from foreign medical schools. T1 -
494
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
ajority of respondents indicated they had been
Lined in interpersonal skills, patient education tech-
ques, or patient tracking/monitoring procedures,
it most instruction occurred after medical school,
fty-three percent of the sample indicated that their
rrent specialty area was general or family practice,
id 47 percent specialized in internal medicine; ap-
oximately 10 percent reported expertise in more
an one specialty. Sixty-eight percent of the respon-
nts maintained a solo practice, 10 percent were en-
ged in a partnership, and 10 percent were involved
a group practice. Twelve percent were either resi-
nts, administrators, or researchers and were not in-
ided in further analyses so that the data would re-
ct only the attitudes and behaviors of private prae-
[e physicians directly involved in patient treatment.
The median number of office hours scheduled per
"ek was 28 and the time spent per patient visit was
proximately 16 minutes. The number of patients
ing treated for hypertension varied widely among
spondents with the typical physician treating ap-
oximately 16 percent of patients for this condition,
le techniques used to assess regimen compliance by
e physicians included (in order of descending use):
nod pressure cheeks, patient self-reports, diet re-
rts, pill counts, reports of exercise activities, reports
salt level intake, consultation with the pharmacist,
id serum drug monitoring. The most frequently used
:hniques were blood pressure checks and patient
ilf-reports (89 and 75 percent of the sample, respee-
rely), although most respondents reported the use of
;ultiple techniques.
[Respondents varied in their estimates on the per-
ntage of time patients complied with instructions in
rious areas. Respondents estimated greatest com-
ianee for appointment-keeping and pill-taking and
jist compliance for diet, exercise, and self-monitoring,
le percentage unable to estimate compliance rates
inged from 1 percent for appointment-keeping to 19
rcent for self-monitoring.
Although 97 percent of the respondents thought
at the physician should have primary responsibility
r counseling the noncompliant patient, as many as
) percent, when confronted with noncompliant pa-
*nts, reported feelings of frustration. Other reactions
?re ambivalence, anger, sense of failure, resignation,
mpathy, and challenge.
The distribution of behavioral responses to patient
incompliance was essentially bimodal, i.e. 63 percent
all respondents reported that they would attempt to
termine the cause of noncomplianee and 47 percent
dieated they would admonish the patient. Very few
spondents indicated they would suggest another
aysieian, refer the patient to a specialist, or take no
tion.
rhe strategy most commonly employed to promote
.mpliance in hypertensive patients was individual
lunselingby the physician (84 percent of the sample),
her educational strategies less frequently used were
dividual counseling by a nonphysieian (22 percent),
ogrammed instruction (19 percent), and small and
ge group instruction (6 and 5 percent, respectively).
The most widely used behavioral strategies (75 to 79
ireent of the sample) were tailoring the treatment to
dividual needs, reinforcement through praise, and
I
family involvement. Approximately half of the respon-
dents also reported use of graduated treatment regi-
mens and self-monitoring for this purpose. The least
commonly used behavioral strategies were support
groups (14 percent) followed by reinforcement through
contracts and incentives (28 percent).
The practice of scheduling individual rather than
block appointments and reducing the waiting time to
see the physician were the organizational strategies
most widely used to promote compliance in this pa-
tient population (62 and 44 percent of the sample,
respectively). Phone call reminders also were used by
27 percent of the respondents for this purpose. Other
organizational strategies (i.e. special referral clerks,
mail reminders, cheeking with the pharmacist, and
home visits) were used by only 1 1 to 18 percent of this
group.
One of the objectives of the study was to determine
whether the physician’s use of specific compliance-
promoting strategies was related to specific profile
eharaeteristies. To examine this question, respondents
were categorized according to the following variables:
age (under 36, 36 to 48, 49 to 57, 58 to 67, and over
67), date of graduation from medical school
(pre- 1940s, 1940 to 1949, 1950 to 1959, 1960 to 1969,
1970 to present), and number of years in present prac-
tice (less than 10, 10 to 19, 20 to 29, 30 to 39, and
more than 40). The categories within each variable
then were compared through chi-square tests on
utilization of various strategies. The results of these
analyses (Table 1) revealed a number of significant
relationships, i.e. younger physicians were more likely
than older physicians to use mail reminders to facili-
tate compliance (xI 2= 16.75, df=4, P<.01) and to allow
nonphysicians to participate in patient counseling
(x2= 19.59, df=4, P<.001). Consistent with the above,
recent graduates from medical school were more likely
than earlier graduates to employ the above strategies
(x2 = 12.07, df=4, PC. 05 and x2 = 20.42, df=4, PC.001,
respectively) as well as to use phone reminders
(x2= 10.17, df=4, PC.05) and self-monitoring tech-
niques (x2= 12.24, df=4, PC.05) to increase com-
pliance. Similarly, the number of years in practice was
inversely related to use of mail reminders (x2= 10.96,
df=4, PC.05), patient self-monitoring techniques
(x2= 10.87, df=4, PC.05), and nonphysieian counsel-
ing (x2= 14.60, df=4, PC.01). In addition, physicians
with newer practices were more likely than physicians
with more established practices to tailor treatment
regimens to individual patient needs (x2= 10.83, df=4,
PC.05).
The relationship between strategy usage and educa-
tional background also was evaluated. Respondents
were compared on the basis of whether they received
their medical education in domestic or foreign institu-
tions. This analysis showed only one significant result,
i.e. American-educated physicians were more likely
than foreign-educated physicians to use individually
scheduled appointments rather than block appoint-
ments (x2 = 9.20, df=l, PC. 01). Respondents also were
compared on the basis of previous training in inter-
personal skills, patient education techniques, and pa-
tient tracking/monitoring techniques by source of
training (i.e. medical school, residency, or post-
residency instruction). The results of these analyses
|*L. 81— NUMBER 6— JUNE 1984
495
TABLE
2
—
Percentage of Respondents Using Compliance-Promoting Strategies Differing Significantly
On a Chi-Squcire Test by Prior Training in Interpersonal Skills
Strategy Used
Source of Prior Training
Medical School
Residency
Postresidency
No
Yes
X2
(df= 1 )
No
Yes
X2
(df= 1 )
No
Yes
X2
(df= 1)
Home visits
17
36
6.49*
15
33
5.55*
—
—
—
Reduced waiting time
—
—
—
—
—
—
47
69
5.49*
Pharmacist check
—
—
—
11
31
6.45*
—
—
—
Family support
—
—
—
—
—
—
77
92
5.46*
Support groups
—
—
—
13
30
5.12*
10
33
8.91*
Self-monitoring
52
75
7.24+
52
73
5.69*
—
—
—
Contractual agreements
—
—
—
29
52
6.76+
27
50
6.13*
Physician counseling
—
—
—
89
99
5.50*
86
99
7.88+
Programmed instruction
19
34
4.40*
16
37
7.49+
—
—
—
*P<.05
+PC.01
Note; Data for nonsignificant differences have been omitted.
TABLE
3
Percentage of Respondents Using Compliance-Promoting Strategies Differing Significantly
On a Chi-Square Test by Prior Training in Patient Education
Strategy Used
Source of Prior Training
Medical School
Residency
Postresidency
No
Yes
X2
(df= 1)
No
Yes
X2
(df= 1)
No
Yes
X2
(df= 1 )
Home visits
18
37
6.07*
—
—
—
—
-
—
Referral clerks
12
25
3.86*
1 1
26
4.47*
—
—
—
Reduced waiting time
—
—
—
—
—
—
50
69
4.55*
Support groups
13
36
9.21 +
12
33
8.21 +
11
32
6.86+
Self-monitoring
52
80
9.04+
51
78
8.86+
—
—
Contractual agreements
29
57
9.73+
29
57
9.78+
—
—
Programmed instruction
18
39
6.78+
14
42
11.56+
13
31
5.26*
*P<.05
+PC.01
Note: Data for nonsignificant differences have been omitted.
(Tables 2, 3, and 4) suggest that training in any of the
above patient management areas enhanced the use of
compliance strategies (i.e. home visits, reduced waiting
time, support groups, self-monitoring, contractual
agreements, and programmed instruction) and the ef-
fects on other strategies varied as a function of the
specific type of training. Various strategies also were
affected differently as a function of source of training,
with most effects attributable to training during resi-
dency.
The use of strategies also was compared to the
number of office hours scheduled per week, the aver-
age time spent with patients, the percentage of hyper-
tensive patients, and the time spent with these pa-
tients. No significant relationships were found.
The final analysis examined the number of com-
pliance strategies used, by strategy type, and the extent
to which these values were affected by profile charac-
teristics. This analysis showed that the mean numb
of organizational and educational strategies used 1
all respondents was 1.93 and 1.33, respectively, wher
as the mean number of behavioral strategies used w;
3.75. Table 5 shows the mean number of compliant
strategies reported within each strategy type, by profi
variable, where significant differences were four i
through analysis of variance. These results general
are consistent with those found for individu
strategies; namely, the number of organizational ar
behavioral (but not educational) strategies used we
affected negatively by age* (F=2.55, df= 4,204, P<.C
and F=4.24, df= 4,204, PC. 05, respectively) anj
*While the mean number of strategies used showed a mon
tonic relationship for age and related factors, postb
analyses using Duncan's Multiple Range Tests failed to dei
onstrate sharp differences between adjacent age and ag
related groupings.
496
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
TABLE 4
Percentage of Respondents Using Compliance-Promoting Strategies Differing Significantly
On a Chi-Square Test by Prior Training in Patient Monitoring Techniques
Strategy Used Source of Prior Training
Medical School Residency Postresidency
No
Yes
X2
(df= 1)
No
Yes
X2
(df= 1 )
No
Yes
"L, II
** t—
■a
Home visits
—
—
—
15
33
5.07*
—
—
—
Reduced waiting time
—
—
—
48
71
5.58*
—
—
—
Support groups
16
38
6.36*
14
33
5.50*
12
33
6.96+
Self-monitoring
55
84
7.06+
49
86
15.45+
—
—
—
Contractual agreements
33
58
5.51*
29
64
13.71 +
—
—
—
Graduated regimens
—
—
—
—
—
—
71
88
4.86*
Programmed instruction
20
44
6.48*
18
40
6.66
15
31
3.95*
*P<.05
+PC.01
Note: Data for nonsignificant differences have been omitted.
TABLE 5
Mean Number of Organizational, Behavioral, and Educational Strategies Used
Differing Significantly on an Analysis of Variance by Selected Profile Characteristics
Compliance Strategies
Organizational
Behavioral
Educational
Age
Under 35
2.4
3.8
—
36-48
2.2
4.3
—
49-57
1.9
4.2
—
58-67
1.6
3.7
—
Over 68
1.5
2.7
—
F (4,204) = 2.55*
F (4,204) = 4.24*
—
Year of Graduation
Pre- 1 940s
1.5
2.7
1.0
1940s
1.6
3.7
1.3
1950s
1.8
4.1
1.4
1960s
2.2
4.5
1.6
1970s
2.7
4.3
1.6
F (4,198) = 4.12*
F (4,198) = 6.29+
F (4,198) = 2.88*
Years in Practice
0-9
2.5
4.3
—
10-19
2.0
4.3
—
20-29
1.8
4.1
—
30-39
1.6
3.6
—
Over 40
1.6
2.8
—
F (4,195) = 2.98*
F (4,195) = 4.83*
—
*P<.05
+PC.001
Note: Data for nonsignificant
differences have been omitted.
mber ofyears in present practice (F=2.98, df=4,195,
.05 and F=4.83, df=4,195, P<,05). Similarly, the
mber of strategies used (for all strategy types) was
eeted positively by year of graduation from medical
iool, with the strongest effects evidenced on the use
behavioral strategies (F=6.29, df=4,198, P<.001).
lally, the use of compliance strategies was related
'ectly to previous eoursework in patient manage -
°nt techniques (Table 6). The number of behavioral
d educational strategies used was affected positively
by previous eoursework in patient track-
ing/monitoring techniques. These educational ellects
ranged from weak (F=4.04, df= 1,161, P<.05) to moder-
ately strong (F= 13.35, df= 1,134, P<.001 ), according to
strategy type and level of instruction.*
*A post hoc analysis of variance (factors: type and level of
training) failed to show tiny consistent relationship between
number of strategies used (for all strategy types) and type of
patient management skill training or between number of
strategies used and the level at which the instruction was
received.
'L. 81— NUMBER 6— JUNE 1984
497
TABLE 6
Mean Number of Organizational, Behavioral, and Educational Strategies
Used Differing Significantly on an Analysis of Variance by Prior
Training in Patient Management Techniques
Prior Training
Interpersonal Skills
Medical School
No
Yes
Residency
No
Yes
Postgraduate
No
Yes
Patient Education
Medical School
No
Yes
Residency
No
Yes
Postgraduate
No
Yes
Patient Tracking/
Monitoring
Medical School
No
Yes
Residency
No
Yes
Postgraduate
No
Yes
Organizational
1.8
2.4
F (1,169) = 5.03*
1.8
2.6
F (1,137) = 7.45
*P<. 05
+PC.01
+PC.001
Note: Data for nonsignificant differences have been omitted.
Compliance Strategies
Behavioral
3.6
4.4
F (1,138) = 5.67*
3.9
4.5
F (1,161) = 4.04*
3.7
4.6
F (1,141) = 6.95+
3.8
4.5
F (1,135) = 5.49*
3.6
4.9
F (1,137) = 13.35+
3.8
4.7
F (1,134) = 7.93+
Educational
1.3
1.6
F (1,169) = 4.85*
1.2
1.6
t i
F (1.152) = 5.88*
1.2
1.5
F (1,138) = 4.16*
1.3
1.7
F (1,161) = 6.35*
1.2
1.7
F (1,141) = 8.57+
1.2
1.6
F (1,135) = 7.56+
1.4
1.9
F (1,149) = 7.78+
1.3
1.7
F (1,137) = 5.99*
1.2
1.6
F (1,134) = 7.16+
498
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1:
A posthoc analysis of variance (factors: age group,
nd level and type of training) indicated that the total
mount of variance in the number of strategies used,
xplained by age and prior training in patient manage-
ment techniques (13 percent), was substantially less
man the sum of these separate effects (22 percent),
uggesting the possibility of a relationship between
ge and prior training. To examine this, chi-square
bsts were conducted between age group and level of
-aining and between age group and type of training,
he only significant relationship was found between
ige and interpersonal skills training in medical school
c2=l 1.5, df= 4, P<,05). Specifically, physicians in the
[oungest age group (36 and under) were more likely
p have received such training than those in any of the
emaining groups.
UMMARY AND IMPLICATIONS
; The survey revealed that most hypertensive patients,
i the opinion of their physicians, do not comply fully
ith instructions in any of the areas surveyed and
[how poorest performance in the areas of self-monitor-
lg, exercise, and diet. Although almost all respondents
urveyed were concerned about patient non-
mmpliance and used a variety of techniques to
leasure it, attempts to remedy the problem were lim-
ed in scope. The strategy employed most often in
attempts to promote compliance was individual coun-
ting by the physician with other educational
trategies used less frequently. More than half of the
espondents reported using a variety of behavioral
Strategies including tailoring the treatment to individ-
al needs, reinforcement through praise, family in-
jDlvement, and graduated regimens. Fewer respon-
dents reported using compliance-promoting organiza-
jonal strategies, except for scheduling individual as
ipposed to block appointments.
The analyses also showed that the likelihood of a
hysician employing certain compliance-promoting
rategies was inversely related to age and number of
ears in present practice and directly related to recent
raduation from medical school. In addition, the use
f certain strategies appeared to be enhanced by
revious exposure to educational programs in inter-
ersonal relations, patient education, and patient
'acking/monitoring procedures, with effects varying
xording to type and level of training. Furthermore,
interpersonal skills training in medical school ap-
peared to be most common among the youngest phy-
sicians, perhaps explaining why this group was most
likely to take action against noncompliance. A posthoc
analysis of variance failed to show any consistent rela-
tionships between the number of strategies used (for
all strategy types) and type of patient-management
skill training or between number of strategies used
and the level at which the instruction was received.
These findings have implications for the education
and training of medical students, residents, and prac-
ticing physicians. In order to enhance patient-manage-
ment capabilities, undergraduate, residency, and post-
graduate medical programs should expand
coursework in patient education, interpersonal skills,
and patient tracking/monitoring techniques. In ad-
dition, continuing education courses should be de-
veloped for the more established physician to stimu-
late interest in and knowledge of available compliance-
promoting strategies. Such programs would be
beneficial not only to physicians with large hyper-
tensive patient loads but to those who deal with other
chronic conditions where noncompliance typically is
problematic.
REFERENCES
1. Caplan RD, Robinson EA French JR Jr, Caldwell JR
Shinn M: Adhering to Medical Regimens: Pilot Experiments
in Patient Education and Social Support Ann Arbor, MI, The
Institute for Social Research, The University of Michigan,
1976.
2. Podell RN, Gaiy LR Compliance: A problem in medical
management. Am Fam Physician 13:74-80, 1976.
3. Finnerty FA Jr: The compliance problem in hyper-
tension, in Freis ED (ed) in Current Status oj Modern Ther-
apy (Volume 1). Baltimore, MD, University Park Press, 1978,
pp. 151-160.
4. Haynes RB, Gibson ES, Hackett BC, Sackett DL, Taylor
DW, et al.: Improvement of medication compliance in uncon-
trolled hypertension. Lancet 1:1265-1268, 1976.
5. Hussar DA Patient noncompliance. J Am Pharm Assoc
15:183-190, 1975.
6. Haynes RB, Mattson ME, Englebretson TO Jr: Trends in
the implementation of strategies to improve compliance in
hypertensives, in Patient Compliance To Prescribed Anti-
hypertensive Medication Regimens: A Report to the National
Heart Lung, and Blood Institute. DHHS Publication No. (NIH)
81-2102. Washington, D.C., U.S. Government Printing Office,
1980, pp. 165-228.
7. Oppenheim AN: Questionnaire Design and Attitude
Measurement New York NY, Basic Books, Inc., 1966, pp.
33-35.
[OL. 81— NUMBER 6— JUNE 1984
499
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500
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Zase Report: Hyperprolactinemia in a
Patient with Pseudotumor Cerebri
Michael Goldman, m.d., and Aaron Rabin, m.d., englewood*
Hyperprolactinemia has been associated with many intracranial
disorders including sella andparasella tumors and the empty-
sella syndrome . This case report documents the occurrence of
hyperprolactinemia in a patient with pseudotumor cerebri .
Hyperprolactinemia has been as-
sociated with multiple con-
ditions. These include pituitary
iumors, the empty-sella syndrome, drug ingestion, and
lypothyroidism.1 The occurrence of elevated prolactin
levels in a patient with pseudotumor cerebri has not
teen described previously. A case describing this situ-
ition is presented.
:ase history
A 26-year-old white female complained of blurred
dsion described as “spots in front of her eyes." No
>ther symptoms were described. Her past medical his-
ory was notable for irregular menses (eveiy six to ten
fjveeks) without galactorrhea. She had taken
etracycline for three years for acne, although it was
iiseontinued three months before admission. Physical
examination revealed the patient to be slightly over-
weight (125 pounds) with a blood pressure of 120/80
jand a regular pulse at 72. Except for bilateral
papilledema, no other abnormal findings were noted.
CAT scans of the head and pituitary gland with and
without contrast were normal. Formal visual fields
were normal. Measurement of a lumbar puncture
showed an opening pressure of 450 mm of water (nor-
mal 180). The cerebrospinal fluid was clear with a
normal chemical profile. Laboratory data revealed a
normal CBC, SMA 12, electrolytes, T3 resin, T4, TSH,
parathyroid hormone, and calcium levels. Prolactin
was elevated to 31.4 ng/ml (normal: 6 to 22). The pa-
tient was treated with Lasix", 40 mg daily, with reduc-
tion of her symptoms. No change in her menstrual
activity was reported. Prolactin was not remeasured
during this time.
Three months later, she returned with her original
complaint, and mild bilateral papilledema again was
noted. A repeat lumbar puncture showed an elevated
pressure of 410 mm of water with normal fluid
analysis. Further laboratory data demonstrated a nor-
mal level of cortisol, dehydroepiandrosterone sulfate,
T3 resin, and T4. LH measured 10 MlU/ml (normal 7
to 24) while FSH was a 3 MlU/ml (normal 4 to 25).
Prolactin again was elevated at 64 ng/ml. The patient
then was treated with Diamox". Improvement of her
papilledema was noted along with diminution in the
severity and frequency of her original visual complaint.
DISCUSSION
Increased prolactin levels may result from in-
tracranial problems (pituitary tumors and the empty-
sella syndrome), extracranial causes (drug ingestion
and hypothyroidism), or unknown ("idiopathic”)
etiologies.1 The association of increased prolactin
levels and pseudotumor cerebri has not been reported
*From Englewood Hospital where Dr. Goldman is Attending,
Department of Medicine, and Dr. Rabin is Attending, Depart
men I of Neurology. Correspondence may be addressed to Dr.
Goldman, 600 Palisade Avenue. Englewood Cliffs, NJ 07632.
VOL. 81— NUMBER 6— JUNE 1984
501
previously. One case report noted elevated prolactin
levels in the patient with the empty-sella syndrome
who had a history of pseudotumor cerebri.2
Pseudotumor cerebri is defined as a constellation of
symptoms and signs including headache, papilledema,
and increased intracranial pressure from causes gen-
erally thought to be benign.
Some authors feel that chronic raised intracranial
pressure may lead to an empty-sella syndrome.3
Etiologies (through uncertain mechanisms) for
pseudotumor cerebri, include endocrine and nonen-
docrine causes. The former include adrenal, ovarian,
parathyroid, or thyroid dysfunction, and the latter in-
clude drugs (such as tetracycline) and intracranial ve-
nous thromboses. However, abnormalities in prolactin
secretion have not been reported.
The coexistence of pseudotumor cerebri and
pituitary tumors or empty-sella syndrome to account
for the elevated prolactin levels was excluded by a nor-
mal CAT scan of the pituitary gland. Similarly, second-
ary causes for increased levels (drugs and
hypothyroidism) were excluded by our studies. T ■
role of the elevated prolactin level in this relationsE
to pseudotumor cerebri remains speculative at t
present time.
A case of pseudotumor cerebri alnd hyp<
prolactinemia is reported. This association has r
been described previously and should be added to t
list of syndromes found to have elevated prolact
levels.
REFERENCES
1. Kleinberg DL, Noel GL, Frantz AG: Galactorrhea: A stu
of 235 eases, including 48 with pituitary tumors. N Eng ■
Med 296:589-600, 1977.
2. Futterweit W: Galactorrhea, amenorrhea, hyp< /
prolactinemia, and pseudotumor cerebri in a patient wi .
primary empty-sella syndrome: Case report with review of t
literature. Mt Sinai J Med 49(6):514-518, 1982.
3. Foley KM, Posner JB: Does pseudotumor cerebri cau
the empty-sella syndrome? Neurology 25:565-569, 1975.
I
I
t
i
502
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Pharmacological Basis of Therapeutics:
/Icosanoids— Mediators of Biological Functions*
Donald J. Wolff, ph.d., piscataway**
Eicosanoids are locally generated and locally acting hormones
most commonly derived from arachidonic acid— a precursor of
two major classes of biological regulatory molecules:
\ prostaglandin-like substances and leukotrienes.
Eicosanoid is a term used to de-
scribe a series of locally gener-
ated and locally acting
jDrmones or autocoids which are oxidative
etabolites of endogenous 20-carbon, unsaturated
tty acids. The most common such fatty acid in hu-
ans is arachidonic acid (5,8,11,14 eicosatetraenoic
:id). Arachidonic acid is chemically released from
lembrane-bound phospholipid by hydrolysis
'iitalyzed by the enzyme phospholipase . The activity
' phospholipase A? is enhanced by Ca2+ whose con-
mtrations intracellularly are elevated in response to
Siverse mechanical and neurohumoral stimuli. The
irachidonic acid thus generated serves as the
letabolic precursor of two major classes of biological
(pgulatory molecules, the prostaglandin-like
abstanees and the leukotrienes (Figure).
yclooxygena.se
1 The prostaglandin-like substances depend for their
ormation on the actions of an enzyme cyclooxygenase,
ound to intracellular membranes, which introduces
2 into the fatty acid at carbon 15 and effects a cyclic
earrangement of its carbon atoms. This action forms
ubstances called cyclic endoperoxides which are sub-
ject to four different types of isomerization reactions
o generate, respectively, prostacyclins, thromboxanes,
r prostaglandins of the E or F series. Different cells
iroduce a different spectrum of these products de-
pending upon the constitutive level of isomerases
characteristic of the particular type of cell. The
prostaglandin-like substances can be produced by vir-
tually every tissue and have been implicated as
mediators of an impressively diverse array of func-
tions. Furthermore, diverse pathological states are ac-
companied by alteration of their concentrations, which
are proposed to contribute in part to the discomforting
symptomatology of these conditions. For example,
elevated endometrical prostaglandin F2a accompanies
primary dysmenorrhea1 elevated prostaglandin E2 ac-
companies pyrogen-induced fever,2 and elevated
prostaglandins are found in synovial fluid in diverse
arthropathies.3
Interest in the prostaglandin-like substances has
been enhanced by the observation that aspirin and the
‘This article, third in a series, prepared under the leadership
of Bruce McL. Breckenridge, M.D., Chairman, Department of
Pharmacology, UMDNJ-Rutgers Medical School, is a brief re-
view of recent advances in pharmacology and related
preclinical sciences, which will help readers to understand
the action of new and established therapeutic agents. The
reviews do not consider indications for specific drugs, incom-
patibilities, or dosage forms, which can be found in the AMA
Drug Evaluations. 5th Edition. 1983.
“From the Department of Pharmacology. UMDNJ-Rutgers
Medical School, Piscataway. NJ 08854. Correspondence may
be addressed to Bruce McL. Breckenridge. M.D.. Chairman.
Department of Pharmacology, UMDNJ-Rutgers Medical
School, P.O. Box 101, Piscataway, NJ 08854.
OL. 81— NUMBER 6— JUNE 1984
503
Figure — Pathways for generation of eieosanoids.
rapidly growing number of nonsteroidal anti-inflam-
matory drugs are specific inhibitors of cycloox-
ygenase.3 The rank order of potency of these drugs
inhibiting cyclooxygenase in vitro parallels their
potency as anti-inflammatory agents in vivo.
Furthermore, several of these drugs exist as stereo-
specific isomers, with only one isomer showing both
activities. Compatible with the proposal that inhibi-
tion of cyclooxygenase is the molecular basis of action
of nonsteroidal anti-inflammatory drugs is the clinical
observation that these agents, of widely varying
chemical structure, are uniformly antipyretic and
capable of alleviating the discomforting symp-
tomatology of both primary dysmenorrhea and diverse
arthropathies.
A major advance in appreciating the role of
araehidonic acid derivatives in diverse patho-
physiological states emerged from studies directed to
understanding the molecular basis of action of the
anti-inflammatory steroids. In 1979, Hirata and his
colleagues reported the observation that anti-inflam-
matory steroids induced in neutrophils the synthesis
of a membrane-bound protein inhibitor of the enzyme
phospholipase the enzyme responsible for the in-
tracellular release of araehidonic acid.4 They called this
inhibitor, lipomodulin. Glucocorticoids had been
known for many years to alleviate the symptomatology
of asthma immediate hypersensitivity reactions, and
diverse inflammatory states. These actions are more
extensive than those of aspirin and the nonsteroidal
anti-inflammatory drugs and suggested that deri-
vations of araehidonic acid, generated by a pathway
other than the cyclooxygenase pathway, might be in-
volved in genesis of these drug actions. These specu-
lations are supported by the recent elucidation of a
second pathway for araehidonic acid oxygenation in
leukocytes.
LEUKOT RIENES
In an attempt to identify products generated from
araehidonic acid in inflammatory cells, poly-
morphonuclear leukocytes were exposed to C'Mabelec
material. Using reverse-phase high pressure liquic
chromatography, Samuelsson and coworkers identi
field the formation of a key intermediate 5,(
oxido-7,9,1 1,14 eicosatetraenoic acid (leukotriene A4
in a new metabolic pathway.5 Leukotriene At now i:
known to have two major metabolic fates. It can b<;
hydrolyzed to form leukotriene B4 or alternately car
react with the endogenous tripeptide, glutathione, tc
form a peptidolipid called leukotriene C4. The amine
acids glutamic acid and glycine can be removed se
quentially from this structure by intracellular;
proteases to form leukotrienes D and E. The tem
leukotriene was chosen for these compounds because
they were discovered in leukocytes and contain as £j
common structural feature a conjugated triene
Samuelsson and his eoworkers established that slow
reacting substance of anaphylaxis, a potent smooth
muscle contracting substance released during
asthmatic attacks and other types of immediate hyper
sensitivity (allergic) reactions, was a mixture o
leukotrienes C, D, and E. The proposed structures foi
leukotrienes have been confirmed by total ehemica
synthesis. Such syntheses have made available large
quantities of purified leukotrienes for determination
of their biological effects and refinement in the tech-j
niques for their specific assay.
The peptidoleukotrienes C, D, and E have been
shown to be extraordinarily potent bronchoconstric-
tors in man.6 When administered as an aerosol, the>
are 100 times as potent as histamine. Studies with
bronchi from atopic patients sensitive to birch pollen
have implicated leukotrienes as mediators of
anaphylaxis. Incubation of atopic lung tissue with al-
lergen resulted in formation of leukotrienes C, D, and
E. Their formation was blocked by an experimental
drug, U-60257, at concentrations which blocked al l
lergen- induced tissue contraction. Histamine an-
tagonists and cyclooxygenase inhibitors were ineffec-
tive. These findings suggest that leukotriene an-
tagonists, or inhibitors of leukotriene formation, could
504
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
I of value in the treatment of bronchial asthma.
Recent studies, in animal systems, have identified
pfound mierovascular actions of the pep-
iloleukotrienes. Using a hamster cheek pouch prep-
[ation in vivo, leukotrienes C, D, and E all induced
i creased vascular permeability at concentrations five
[ousand-fold lower than histamine.7 These
j bstanees produced intense contraction of terminal
iterioles and endothelial leakage at postcapillaiy
nules, actions compatible with their involvement in
j.ema formation in local, acute inflammatory
isodes.
Other studies have identified leukotriene B as an
tivator of human neutrophils and as a potent
lemotactie substance toward polymorphonuclear
.ikoeytes, eosinophils, and monocytes.8 The potential
volvement of leukotrienes as mediators of immediate
rpersensitivity reactions and inflammation seem ob-
ous. The development of specific, in vivo, antagonists
leukotrienes and further elucidation of the mecha-
sm of their formation and action rigorously is being
>ught and shows promise for the development of new
seful therapeutic agents.
JMMARY
iEieosanoids are locally generated and locally acting
rrmones derived metabolieally from naturally oeeur-
ng 20-earbon, unsaturated fatty acids, most corn-
only arachidonic acid. Araehidonie acid is a
i'eeursor of two major classes of biological regulatory
olecules, the prostaglandin-like substances and the
recently characterized leukotrienes. Leukotrienes have
been identified as extraordinarily potent
bronchoeonstrietors, leukocyte chemoattractants, and
regulators of mierovascular tone and permeability.
Their formation is believed responsible for much of the
symptomatology of acute allergic reaction, bronchial
asthma attacks, and aspirin sensitivity.
REFERENCES
1. Chan YW: Prostaglandins and nonsteroidal anti-inflam-
matory drugs in dysmenorrhea. Annu Rev Pharmacol Toxicol
23:131, 1983.
2. Feldberg W, Gupta KP: Pyrogen fever and prostaglandin-
like activity in cerebrospinal fluid. J Physiol 228:41, 1973.
3. Moneada S, Vane JR- Mode of action of aspirin-like drugs.
Adv Intern Med 24:1, 1979.
4. Hirata F, Schiffmann E, Krishnamoorthy V, Salomon D,
Axelrod J: A phospholipase A2 inhibitory protein in rabbit
neutrophils induced by glucocorticoids. Proc Natl Acad Sci
77:2533, 1980.
5. Samuelsson B: Leukotrienes: Mediators of immediate
hypersensitivity reactions and inflammation. Science
220:568, 1983.
6. Weiss JW, Drazen JM, Coles N, McFadden ER Wilier PF,
Corey EJ, Lewis RA Austen KF: Bronehoconstrictor effects of
leukotriene C in humans. Science 216:196, 1983.
7. Hedgvist P, Dahlen SE: Pulmonary and vascular effects
of leukotrienes imply involvement in asthma and inflamma-
tion, in Samuelsson B, Paoletti R and Ramwell PW (ed): Ad-
vances in Prostaglandin, Thromboxane, and Leukotriene
Research. 1982.
8. Ford-Hutchinson AW, Bray MA Doiy MV, Shipley ME,
Smith MH: Leukotriene B, a potent chemokinetic and ag-
gregating substance released from polymorphonuclear
leukocytes. Nature 286:264, 1980.
DL. 81— NUMBER 6— JUNE 1984
505
This Publication
is available in Microform.
Please send additional information for
(name of publication)
Name
Institution
Street
City
State Zip
300 North Zeeb Road, Dept. P R,, Ann Arbor, Mi. 48106
University
Microfilms
Internationa]
506
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Impaired Physicians Program
'REATMENT LOAN FUND
David I. Canavan, m.d., lawrenceville*
The Treatment Loan Fund of the Impaired Physicians Program
helps physician-clients in their time of need. Loans are used for
treatment costs, family support during treatment , and re-entry
expenses. Contributions for this fund are welcomed.
One of the challenges that con-
fronts us in our efforts on behalf
of the “wounded healers” in our
ndst is the economic consequences in the life of the
iipaired physician. As the diseases of impairment
! ogress, his professional performance, his good judg-
lsnt, and the successful management of his personal
fiances are affected.
In the face of declining patient revenues, judgmental
Tors, and lack of attention to appropriate life man-
;ement, it is not at all surprising that economic chaos
jquently accompanies all of the other problems that
isue.
In our efforts to find suitable therapy for these
tents, we often are thwarted by their own economic
stress. One of the first things that seems to go when
ranees get tight is the physician’s own medical
ld/or hospital insurance coverage.
Since the passage of the ATRA (Alcohol Treatment
id Rehabilitation Act) legislation in the late 1970s,
lie insurance carriers in New Jersey have been re-
tired to provide coverage for treatment of alcoholism.
Tien a physician has current coverage, the economic
irden of inpatient treatment is minimal. In the situ-
ion in which the physician’s insurance has been
lowed to lapse, the cost of the treatment often pres-
its an economic burden that the physician-client
innot meet.
An added burden in these cases is the need to take
time away from a practice that already may be eco-
nomically compromised. In these situations, time away
from the office can lead to an absence of income to
meet the needs of the family for economic support.
Both the lack of insurance and the economic dis-
tress of the family are major obstacles in convincing
our colleagues to accept the time requirement and the
economic implications of admission to an inpatient
program.
It is possible in some cases to compromise and ac-
cept an outpatient program as the only viable alterna-
tive, but this is not necessarily the preferred route.
Even in the case of an actively employed physician,
the occasional need for long-term therapy (e.g. four to
six months of residential treatment) can lead to
serious cash-flow problems.
It was precisely because of these problems that the
concept of a Treatment Loan Fund surfaced. In my
travels around the country, interacting with other
state impaired physicians programs, this same issue
regularly has surfaced as a common problem and the
need for a vehicle to assist physicians is readily per-
ceived.
*Dr. Canavan is Medical Director, Impaired Physicians Pro-
gram. Correspondence may be addressed to Dr. Canavan,
Medical Society of New Jersey, Two Princess Road, Law-
renceville, NJ 08648.
PL. 81— NUMBER 6— JUNE 1984
507
Since my arrival in Lawrenceville in September
1982, I have pursued actively the acquisition of funds
for this purpose. My initial efforts were directed to the
pharmaceutical houses that are based in New Jersey.
I personally contacted ten companies and was success-
ful in obtaining contributions to our fund from five of
these. To date, these contributions amount to $19,250
with an additional $17,000 pledged over the next two
years.
Two other organizations whom I addressed about
our New Jersey program provided an additional $350
for our fund.
We recently have developed a policy of allocating
interest on a monthly basis to the unused grant funds
from our generous program supporters. This interest
will be credited to the Treatment Loan Fund.
The monies in this fund are available to physician-
clients of our program who are in real need. The funds
will be provided to the physicians as low-interest (3
percent per annum) loans.
At the end of the first year, the accrued interest will
be due and payable. Thereafter, one-twelfth of the bal-
ance and the month’s interest on the unpaid balance
will be due and payable at the end of each subsequent
month until the balance is paid in full.
Loans may be made for any valid purpose, but ideally
would be limited to: treatment costs; family support
during treatment; and re-entry expenses (e.g. malprac-
tice premiums, family support, relicensure costs).
At present, four loans have been made to cover family
expenses and malpractice premiums.
Our goal is to establish a fund of $100,000 which
would function as a revolving loan fund and it would
be maintained by MSNJ’s financial officer. Income
from the fund balance, interest, and loan repayments
would be used to maintain the fund and to offset any
bad debts generated.
In approaching the pharmaceutical corporations,!
recurrent issue has been— what are the doctors theij-
selves doing to support this fund? I have had to ansv
that until recently they have not been asked to parti
pate. Corporate donors have indicated that they woi |
be more willing to participate with the physicians th
in place of the physicians.
For this reason, we asked the Board of Trustees 1;;
approval to solicit our membership for voluntaiy cc
tributions to the Treatment Loan Fund. This w
granted and an ad appeared in the September 19
issue of The Journal soliciting voluntary contrit
tions to the fund. I was overwhelmed by the lack
response. Not one member of The Journal audier i
responded to our ad.
This has prompted me to write the article detaili
exactly what the Treatment Loan Fund is, how
evolved, what our current status is and what our go;
are.
I hope you are encouraged to contribute to our fui
for your suffering colleagues in their hour of need! li
gift is too small (or too large). If you are involved wi
charitable agencies, funds, or foundations that £
seeking appropriate grantees, please plead our cau
or let us know how to do it for you. If you are looki
for additional bequests to add to your will, we wot
be happy to find that this fund has been include;
To start the ball rolling, I am personally making
donation of $100 to the fund. Won't you consider fj
lowing suit within your own ability to do so?
Contributions can be made to the Medical Sock;
of New Jersey, Impaired Physicians Program, Tre;i
ment Loan Fund and may be mailed to: Impaired Phi
sicians Program, Medical Society of New Jersey, Tv
Princess Road, Lawrenceville, NJ 08648.
We’ll keep you posted on the results of this endeavi
!
508
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
OCTORS’
OTEBOOK
Trustees’ Minutes; UMDNJ
[Votes; AMNJ Report; New
Members; Physicians
Seeking Location in
New Jersey
rustees’ Minutes:
pril 15, 1984
A regular meeting of the Board of
ustees was held on April 15, 1984,
the Executive Offices in Law-
nceville. Detailed minutes are on
p with the secretary of your county
edieal society. A summary of sig-
ficant actions follows:
rport of the President . . .
gislation . . . Noted that a com-
unication from the Union County
edieal Society stated that efforts of
e Council on Legislation should
ncentrate on the successful pas-
ge of professional liability bills.
jport of Executive Director . . .
) MSNJ Paid Membership . . .
rted that as of March 31, a total of
i508 members have paid 1984
res.
) MSNJ Financial Statements
Reviewed and approved
lancial statements for the period
iding March 31, 1984.
) Corporate Practice of Medicine
o Reiterated opposition to hospi-
1-owned “for profit” corporations.
) State Board of Medical Exam-
pL. 81— NUMBER 6— JUNE 1984
iners Proposed Ruling on Chiro-
practic Practice . , . Voted to oppose
adoption of proposed rule N.J.A.C.
13:35-7.1 which expands standards
and scope of chiropractic practice.
(5) Legal Services Plan . . , Re-
ferred to the Committee on Medical
Defense and Insurance Dr. Rigg’s re-
port on the Legal Services Plan. Ap-
proved then the following recom-
mendation with the understanding
that the Committee will continue to
monitor the Legal Services Plan:
That the Legal Services Plan be con-
tinued in its present form, since it
provides high quality legal services at a
modest expense to the members of the
Society.
(6) Litigation . . .
(a) Exclusive Anesthesia Con-
tracts . . . Noted the U.S. Supreme
Court upheld the legality of ex-
clusive anesthesia contracts.
(b) Mandatory Participation in
Blue Shield and Ban on Balance
Due Billing . . . Noted that a Massa-
chusetts Federal District Court
ruled that Blue Shield Plan's ban on
balance due billing and refusal to
pay for services of nonparticipating
physicians violates federal antitrust
law.
( 7 ) New Jersey Resident Physician
Selection . . . Authorized attend-
ance of official representative of NJ
Resident Physician Section at MSNJ
Annual Meeting and $ 1 ,000 to offset
expenses of two resident physician
delegates at AMA Annual Meet-
ing— in an effort to encourage mem-
bership.
(8) Study of DRG System . , .
Noted that the federal government
has contracted with Harvard School
of Public Health to study the feasi-
bility of a physician DRG system of
reimbursement.
UMDNJ . . .
Fradulent Documentation . . ,
Noted Dr. Bergen's report on
fraudulent documentation of back-
ground and credentials of individ-
uals in residency programs and
noted there is no documented
evidence of impropriety in New Jer-
sey at this time.
Ad Hoc Committee on Presentation
of MSNJ DRG Position . . . Ap-
proved the following five recommen-
dations:
( 1 ) That two or three knowledgeable
individuals from outside the state of New
Jersey be invited to meet with the Ad Hoe
Committee, to discuss concerns about
DRGs, as an approach in aiding the Ad
Hoe Committee in the presentation of
the MSNJ DRG position.
(2) That a seminar be held on DRG
some time in the early fall, sponsored by
the Medical Society of New Jersey.
(3) That the Medical Society of New
Jersey continue to request an objective
investigation of the DRG Program in New
Jersey, including necessaiy legislative ac-
tivity to further this investigation.
(4) That the Medical Society of New
Jersey investigate knowledgeable and
interested groups to develop alternative
methods of pricing or reimbursement,
and that the staff be asked to investigate
methods of implementation.
(5) That recent articles published in
The New York Times (March 5 and
March 18 issues) on DRGs be sent to the
membership of the Medical Society of
New Jersey, specialty societies, and legis-
lative people through the state. The op-
tion of whether the articles are sent in
complete or summary form is to be at the
discretion of staff.
Also, suggested that copies of a
proposed DRG survey be sent to
members of MSNJ’s DRG Commit-
tee.
Proposed Standards for Licensure
of Ambulatory Care Facilities . . .
Approved a recommendation to ar-
range a meeting with the Com-
missioner of Health and his staff,
representatives from MSNJ, and rep-
resentatives of the NJ Academy of
Family Physicians regarding the re-
vision of the Manual of Standards
Jor the Licensure of Ambulatory
Care Facilities.
Council on Medical Services . . .
Corporate Restructuring of New
Jersey Hospitals . . . Approved the
following recommendation:
That the Medical Society of New Jersey
maintain that the assets of hospital cor-
porations which have been and are being
unbundled should have those revenues
and assets of the unbundled corpor-
ations included in the assets and income
of the hospital for which the rate develop-
ment of the hospital itself is based.
Committee on Medical Aspects of
Sports . . .
Physical Therapy Modalities/Un-
licensed Aides . . . The following
recommendation was referred back
to the Committee:
That the Board of Trustees advise the
State Board of Medical Examiners that
509
the suggested regulation regarding
physical modalities used by unlicensed
physician's aides is unacceptable as writ-
ten, and it neither would be beneficial
nor practical to put the regulations into
effect.
Note: The Committee objected to the
aides being restricted from doing re-
habilitative exercises, that the phy-
sician must see the patient each
time physical treament is given, and
that the physician must be on the
premises when physical therapy or-
ders are being carried out; the Com-
mittee felt the regulation was for the
advantage of physical therapists not
for the benefit of the patient.
Committee on Conservation of
Vision . . .
1984 Eye Health Screening Week
. , , Approved the following rec-
ommendation:
That reimbursement of hotel cost be
made at a maximum rate of 8 1 00 per day.
That reimbursement for land travel be
made at the maximum rate of Si 25 per
trip.
Old Business . . .
Hospital Medical Staff Regulations
. . . Noted that at Hamilton Hospital
the governing board has requested
the medical staff to draft a revision
of bylaws.
New Business . . .
AMA Ad Hoc Committee on
Foreign Medical Graduates . . .
Directed that the name Frank
Campo, M.D., be submitted for nomi-
nation to the AMA Ad Hoc Commit-
tee on Foreign Medical Graduates to
study the problems and concerns of
foreign medical graduates.
UMDNJ’s six schools produel
more than 600 trained personnel 1-
the health sciences professions tl,
year, including about 260 in 0
medical-dental fields.
It is gratifying to be able to rep<
that all 289 members of the Univ
sity’s medical school graduati r
class have secured graduate medw
education appointments.
Of the 1984 class, 254 prospect :
graduates, or 88 percent, obtain
residencies through either t
American Medical Association’s P •
tional Resident Matching Progra
for UMDNJ-New Jersey Medid
School and UMDNJ-Rutgers Medic]
School or the American Osteopatl
Association’s Intern Registrati i
program for UMDNJ-Sehool of C
teopathic Medicine. The other
students obtained residenci
outside of the match programs. i
The percentage of match parti
pants obtaining residencies with
New Jersey rose to 44 percent, frc!
the decline to 38 percent record,
for 1983 graduates. The School
Osteopathic Medicine showed 0
largest increase here, reaching
percent of the class of 1984 j
against 43 percent of the class
1983.
Within the integrated resider
programs at UMDNJ’s core teachi j
hospitals, the percentage of Unit!
States graduates among the re;
dents recruited continued to clin.
reaching 85.2 percent. The numb
of U.S. graduates of foreign medi< I
schools dipped to 1 1 .5 percent, wh
the number of foreign mediii
school graduates remained virtua l
stable at about 3 percent.
The more intense competition f
residencies is reflected in the fa,
that less than half of the allopath
match participants obtained the
first choice. For the class of 196
the percentage going to their firs
choice institutions is 44 percei
while more than half of the class]
of 1982 and 1983 got their fill
choice. Comparisons for osteopath
students are not available.
Medical advances at UMDI
schools are helping couples wl
want to become parents of healt
babies. A new diagnostic techniq
that can detect genetic disorders
the fetus as early as seven or eig
weeks into a pregnancy is being ij ]
fered by the UMDNJ-New Jersr '
Medical School.
The procedure, known
That the Eye Health Screening Pro-
gram be conducted during the week of
September 17, 1984.
Ad Hoc Committee on Study on
PRO . . . Approved the following rec-
ommendation:
That there be a formal bylaw rela-
tionship with the PRO Federation, in-
cluding the Medical Society of New Jer-
sey and the New Jersey Association of
Osteopathic Physicians and Surgeons,
and that there be official representation
on the Board of Trustees of the PRO Fed-
eration. (Or, that some similar rela-
tionship be advanced.)
Committee on Finance and Budget
. . . Approved the following rec-
ommendations:
( 1 ) That the budget for the fiscal year
beginning June 1, 1984, and ending May
31, 1985, in the amount of 82,783,400
with 82,062,500 to be raised through
member assessments be adopted.
(2) That the 1985 assessment be set at
8275 per regular dues-paying member.
(No change)
(3) That the 1985 assessment be set at
825 per member for affiliate (no longer
practicing in New Jersey) and associate
members (intems-residents nonlicensed
in New Jersey). (No change)
(4) That there be an assessment for
1985 of 825 per member for licensed
residents provided the individual is in a
residency program entered upon within
a reasonable time after his or her gradu-
ation from medical school. (No change)
(5) That the 1985 assessment be set at
8 10 per student for medical students.
(No change)
Also, approved the following two rec-
ommendations:
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
At its 11th annual commence-
ment on May 23 at the Garden State
Arts Center, the University awarded
honorary Doctor of Science degrees
to three persons who have made
outstanding contributions in the
health sciences. They were:
Dr. Carolyne Kahle Davis, admin-
istrator of the federal Health Care
Financing Administration. Dr.
Davis, who has degrees in nursing,
nursing education, and higher
education administration, was at
the University of Michigan as as-
sociate vice-president for academic
affairs and dean of the School of
Nursing before joining the federal
agency. From 1957 to 1960, she was
a nursing instructor at Mercer Hos-
pital in Trenton.
Dr. Roy P. Vagelos, president of
Merck, Sharp and Dohme Research
Laboratories, Rahway, whose re-
search contributions at the National
Institute of Health, as bioehemistiy
chairman at the Washington Univer-
sity School of Medicine, and at
Merck focused on fatty acids.
Dr. Elizabeth Boggs of Hampton,
first woman president of the Na-
tional Association for Retarded
Citizens and former president of the
New Jersey unit, whose full-time vol-
unteer advocacy played a key role in
the passage of federal legislation for
the developmental disabled and
the securing of the rights of the
handicapped.
510
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
lorionic villi sampling (CVS), is
msidered a breakthrough because
-can be employed at an early stage
pregnancy and because it involves
} penetration of the patient's ab-
)minal or uterine walls. The
-ocedure, being tested nationally
Oder strict federal guidelines, is
me on an outpatient basis at Uni-
arsity Hospital, which is adjacent to
le medical school on the Newark
unpus.
Thus far CVS has proved at least
5 percent accurate in detecting
lown’s syndrome, Tay-Sachs dis-
rse, sickle cell anemia and other
metic abnormalities that were
deviously diagnosed prenatally only
V the process of amniocentesis,
owever, amniocentesis cannot be
me until the 16th week of p reg-
ency and requires a needle to be
lserted through the abdomen into
le sac surrounding the fetus.
Another prenatal test to detect
ippling and often fatal congenital
bnormalities of the embryonic neu-
il tube, which eventually forms the
Irain, spinal cord, and spinal
blumn of the fetus, now is available
it both UMDNJ-New Jersey Medical
chool and UMDNJ-Rutgers Medical
|chool in New Brunswick.
The prenatal test, most accurate
'hen done 16 to 20 weeks into the
iregnancy, is a simple blood test for
Ipha-fetoprotein (AFP), a serum
rotein normally produced almost
kclusively in fetal life.
Neural tube disorders, among the
lost common congenital birth de-
bets in this countiy, include
neneephaly, the absence of brain
nd spinal cord, which is always
atal; spina bifida, which results in
arying extents of paralysis and
rain damage; and hydrocephalus,
n accumulation of fluid on the
•rain, which can be corrected
urgically.
At UMDNJ-School of Osteopathic
ledicine in Camden/Cherry Hill,
he first applicants for in vitro
ertilization are being accepted. Con-
lucted in cooperation with the
ehool’s core teaching affiliate, Ken-
ledy Memorial Hospitals-University
Medical Center, Cheriy Hill Division,
his is the first so-called “test tube
>aby” program in the United States
o be conducted by an osteopathic
ichool.
This is the second program in New
Jersey, and the second for UMDNJ,
o attempt to overcome infertility
problems by a procedure that unites
a woman’s egg with her husband’s
sperm in a laboratory. Achievement
of its first two pregnancies has been
reported by the in vitro program
conducted by UMDNJ-Rutgers Medi-
cal School with Middlesex General
University Hospital, New Brunswick.
AMNJ Report
Paul J. Hirsch, M.D.
President
The Board of Trustees of the
Academy of Medicine of New Jersey
has voted unanimously to grant a
special award, for contributions to
continuing medical education, to
Sylvan E. Moolten, M.D. Dr. Moolten
is well known for organizing high-
quality continuing education
courses. For many years he ran a
weekly Wednesday morning pro-
gram, attended by physicians from
all over the state. This course, held
at Middlesex General Hospital, was
a standard for continuing physician
education. Dr. Moolten retired last
year, as director of this postgraduate
course, which now permanently
bears his name. This special award
was granted at the Academy of Medi-
cine’s Annual Awards Dinner on
May 23, 1984.
The Award to Dr. Moolten was in
addition to the two major awards
which are granted on an annual
basis by the Academy of Medicine.
As previously announced, Alfred A.
Alessi, M.D., received the Edward J.
Ill Award; and Congressman James
Courter received the Citizen’s
Award.
Joseph Ruggles, Associate Direc-
tor for Continuing Education, has
now assumed his office at the
Academy of Medicine. Mr. Ruggles
will be in charge of developing new
educational programs, developing
programs which utilize new and in-
novative techniques, and assessing
the educational needs and wants of
the membership of the Academy of
Medicine.
At the recent meeting of the Board
of Trustees of the Academy of Medi-
cine, final approval was given to a
change in the bylaws, which now
permits application for membership
in the Academy of Medicine to be
made without the need for sponsor-
ship by Academy members. This is
consistent with the Board's policy of
encouraging a broad-based mem-
bership in the Academy of Medicine.
This will allow the Academy to con-
tinue to provide very high-quality
educational programs and activities
for the physicians of New Jersey, at
low cost. We believe that the
Academy of Medicine deserves the
support of the physicians of our
state; and particularly encourages
members of the Medical Society of
New Jersey to become members of
this teaching arm of the Medical So-
ciety of New Jersey.
New Members
The Journal would like to wel-
come the following new members to
the Medical Society of New Jersey:
Bergen County
Avrill R Berkman, M.D., Hackensack
Nicholas V. Campanella, M.D., Fair Lawn
James A Cocores, M.D., Wayne
Arthur R Crowley, M.D., Teaneck
Anne-Marie Filkin, M.D., Leonia
Ivan A Friedrich, M.D., Englewood
Harry Katz, M.D., Ridgewood
Andrew Kunish, Jr., M.D., Fair Lawn
Joseph M. Parian, M.D., Lodi
Asmat U. Quraishi, M.D., Teaneck
Carl J. Renner, M.D., Hasbrouck Heights
William D. Salerno, M.D., Saddle Brook
Howard S. Smith, M.D., Ridgewood
Anita D. Winokur, M.D., Hackensack
Burlington County
Douglas Jay Cohen, M.D., Mount Laurel
Richard K. DeVeaux, M.D., Moorestown
Joseph F. Girone, M.D., Marlton
Robert W. Goldlust, M.D., Willingboro
Isabel C. Guerrero, M.D., West Trenton
Eric N. Kruger, M.D., Medford
James C. Peters, M.D., Mount Holly
Scott R. Sharetts, M.D., Willingboro
Gerald J. Ukrainski, M.D., Moorestown
John Y. Yang, M.D., Maple Shade
Camden County
Ilene S. Cottier, M.D., Cheriy Hill
Miguel L. deLeon, M.D., Cherry Hill
Edward J. Gallagher, M.D., Somerdale
Michael B. Goldstein, M.D., Cherry Hill
Russell S. Golkow, M.D., Stratford
Glenn S. Merewitz, M.D., Cherry Hill
Bariy M. Miskin, M.D., Collingswood
Nancy Ruth Otto, M.D., Camden
S. Habeebur Rahman, M.D., Cherry Hill
Larry S. Rosen, M.D., Cherry Hill
Joseph F. Rubacky, M.D., Blackwood
Tariq Sifat Siddiqi, M.D., Gibbsboro
Linda Stanley, M.D., Marlton
Essex County
Alan H. Burghauser, M.D., Elizabeth
Leslie M. Greenberg, M.D., Mooristown
Bernard J. Lehrhoff, M.D., Millbum
Issac O'Neal, M.p„ East Orange
Andrew B. Stefaniwsky, M.D., Maplewood
Gloucester County
Fiore J. Copare, M.D., Sewell
Norman Feinsmith, M.D., Woodbury
Alan Lawit, M.D., Woodbury Heights
51 1
OL. 81— NUMBER 6— JUNE 1984
Mark A. Lebovitz, M.D.. Woodbury
David I. Olian, M.D., Woodbury
Hudson County
Fred P. Doyle, M.D., Secaucus
John J. Hosay, M.D., Jersey City
Monica Mehta, M.D.. Jersey City
Bernard I. Reimer, M.D., Hoboken
Stephen Thomsen, M.D., Union City
John J. Ursino, M.D., Jersey City
Hunterdon County
Allen J. Kern, M.D., Clinton
Austin H. Kutscher, M.D., Flemington
Mercer County
Louis G. Fares, M.D., West Orange
Timothy C. Gjenvick, M.D., Hightstown
Farid F. Muakkassah, M.D., Trenton
Mark J. Tenenzapf, M.D., Trenton
Middlesex County
Panrmi T. Bais, M.D., Edison
Steven Deak, M.D., New Brunswick
Lawrence D. Frenkel, M.D., New
Brunswick
Enrique A. Rodriguez Paz, M.D.,
Middlesex
Larry E. Shindelman, M.D., Highland
Park
Monmouth County
Savji L. Bhatiya, M.D, Lit tie Silver
Steven M. Feld, M.D., Neptune
SungW. Paik, M.D., Neptune City
Lewis A. Preschel, M.D., Freehold
David J. Sharon, M.D., Long Branch
Morris County
Emil P. Bisaccia, M.D., Morristown
Anthony F. Carolla, M.D., Denville
George M. Chirovsky, M.D., Dover
Joel M. Gottlieb, M.D., Dover
William A. Hardman, M.D., Morristown
Francis M. Jampol, M.D., Dover
Murray S. Las, M.D., Denville
Kenneth W. Meisner, M.D., Dover
Steven W. Papish, M.D., Morristown
David C. Saypol, M.D., Morristown
Stuart E. Shulruff, M.D., Denville
Kirk E. Sperber, M.D., Oak Ridge
Joseph J. Wallis, M.D., Denville
Richard I. Watson, M.D., Morristown
Ocean County
Wayne R. Draesel, M.D., Toms River
Lawrence A. Gaetano, M.D., Toms River
Alfred E. Palmieri, M.D., Toms River
Passaic County
Manuel Alvarez, M.D., Hoboken
Howard A Crystal, M.D., Clifton
Lee D. Kaufman, M.D.. Pompton Lakes
Jerzy S. Kawecki, M.D., Garfield
Robert M. Klein, M.D., Clifton
Roland A. Lascari, M.D., Pompton Plains
Haroutune A. Mekhjian, M.D., Paterson
Mooriath Ramaehandran, M.D., Passaic
Henry Velez, M.D., Paterson
Somerset County
Deborah A. Beiter, M.D., Somerville
Muscu M. Reddy, M.D., Bridgewater
Sussex County
Bartholomew R. D'Ascoli. M.D., Sparta
Union County
Steven J. Berger, MIT, Elizabeth
Desmond E. Smith, M.D., Plainfield
Shekhar T. Venkataraman, M.D., Roselle
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ALCOHOLISM— George W. Miller, Jr„
M.D., 77 Grove St„ Apt. 8, Montclair, NJ
07042. UMDNJ 1980. Available July
1984.
ALLERGY/IMMUNOLOGY— Leonard
Bieloiy, M.D., 688 Concerto La., Silver
Spring, MD 20901. UMDNJ 1980.
Board eligible. Solo preferred, but flex-
ible. Available March 1985.
T.M. Bokhari, M.D., 48 Anderson Pkwy.,
Cedar Grove, NJ 07009. FJMC. Also in-
fectious diseases (pediatric). Board
certified (PED). Group, partnership,
solo. Available July 1984.
ANESTHESIOLOGY— Cau Pham. M.D.,
856 Nelson, Apt. 206, Chicago, IL
60657. Saigon (South Vietnam) 1974.
Group or partnership. Available July
1984.
R.S. Saraiya, M.D., 88-25A 153rd St.,
Apt. 4-F, Jamaica, NY 11432. Baroda
(India) 1978. Group or partnership.
Available August 1984.
FAMILY MEDICINE— Laurence
Levenberg, M.D., 63 Harrowgate Dr.,
Cherry Hill, NJ 08003. SUNY-Upstate
1966. Group, partnership, solo. Avail-
able July 1984.
GASTROENTEROLOGY— Prakash V
Huded, M.D., 80-15 41 Ave., Apt. 606,
Elmhurst, NY 1 1373. Kamatak (India)
1970. Board certified. Solo, group, part-
nership. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, internal medicine. Part-
nership, group, full-time hospital.
Available July 1984.
Neil Tarkin, M.D., 6700 192nd St.,
Fresh Meadows, NY 11365. New York
Medical 1978. Also, internal medicine.
Board certified (IM). Any type practice.
Available July 1984.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia, MO 6520 1 . National Taiwan
University 1977. Also, internal medi-
cine. Board certified. Available July
1984.
INTERNAL MEDICINE— ZUA Farooqui,
M.D., Plaza Professional Bldg.,
Bayshore Rd. and Greenwood Ave., Box
238. Villas, NJ 08251. Aurangabad
Medical College (India) 1972. Boan
eligible. Group or partnership. Avail
able.
H.L. Kirschenbaum, M.D., 780 Woolle
Ave., Staten Island, NY 10314. Ne\
York Medical College 1977. Boar
eligible. Also, gastroenterology. Part'
nership, group, full-time hospita
Available July 1984.
Quang T. Nguyen, M.D., 15 W
Englewood Ave., Bergenfield. NJ 07621
Saigon (South Vietnam) 1967
Subspecialty, nephrology. Boan
eligible. Any type practice. Availabl
July 1984.
Claudia Anne Pollet, M.D., 611:
Parkway Dr., Baltimore, MD 21217
Mount Sinai 1981. Board eligible1
Salaried position in emergency room
clinic, or urgent care center. Availabl
July 1984.
Richard B. Schwarz, M.D., 8300 De’
Longpre Ave., Apt. 204, Los Angeles, ci
90069. NYU 1979. Subspecialty
nephrology. Board certified. Grouf
HMO, hospital. Available July 1984.
Gopal Shah, M.D., 100 Caton Ave., Api
2-G. Brooklyn, NY 1 1218. M.R. Medics
College (India) 1976. Board eligible
Group. Available July 1984.
Neil Tarkirl, M.D., 6700 192nd St
Fresh Meadows, NY 11365. New Yorl
Medical 1978. Also, internal medicine
Board certified (IM). Any type practice
Available July 1984.
Mark F. Tsai, M.D., 1715 Stanford Dr
Columbia MO 6520 1 . National Taiwat
University 1977. Also, gastroenter
ology. Board certified. Available Juf .
1984.
Steven Wolinsky, M.D., 1404 E. 15 St
Brooklyn, NY 1 1230. Case Western Re
serve 1980. Group or partnership I s
Available July 1984.
NEPHROLOGY— Quang T. Nguyen, M.D
15 W. Englewood Ave., Bergenfield, Nf
07621. Saigon (South Vietnam) 1967
Also, internal medicine. Board eligible
Any type practice. Available July 1984!
Richard B. Schwarz, M.D., 8300 De
Longpre Ave., Apt. 204, Los Angeles, C/j
90069. NYU 1979. Also, internal medi
cine. Board certified (IM). Group, HMOj 1
hospital. Available July 1984.
OBSTETRICS/GYNECOLOGY— Balwan
K. Chhatwal. M.D., 6416 Fairfield Ave(
Berwyn, IL 60402. Delhi (India) 1975;
Group, partnership, solo. Available July
1984' lit
Sheela Choubey, M.D., 1 Zirkel Ave.
Piscataway, NJ 08854. Poona (India
1977. Board eligible. Group or partner
ship. Available July 1984.
Edwin R. Guzman, M.D., 1200 E. 98th |
St„ Brooklyn, NY 11236. New Yorl
Medical 1980. Board eligible. Group oil
partnership. Available September
1984.
Atul S. Sheth, M.D., 2951 S. King Dr.
Chicago, IL 60616. Specializing in in
fertility, reproductive endocrinology K
Board eligible. Partnership, single or
multiple-group practice, academia
Available.
512
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Ernest A. Topran, M.D., 3523 Dew-
berry-Southern Oaks, Shreveport, LA
71118, Louisiana State 1 980. Group or
partnership. Available July 1984.
EDIATRICS — Dorothea H. Gross, M.D.,
i 264 Boonton Turnpike, Lincoln Park,
NJ 07035. Geneva (Switzerland) 1950.
: Clinic, group, emergency room, hospi-
. tal, pharmaceutical research (salaried).
Available.
Kusumam Sidharthan, M.D., 222
Yorkshire Ct„ Old Bridge, NJ 08857.
Calicut Medical College (India) 1976.
Board eligible. Available July 1984.
(ADIOLOGY/ NUCLEAR MEDICINE—
Conrad P. Erlich, M.D., 1243 Beacon
St., Apt. 3B, Brookline, MA 02146. Bos-
ton 1976. Board certified. Group or
partnership. Available July 1984.
Mindy M. Horrow, M.D., 131 Pond
Brook Rd., Chestnut Hill, MA 02167.
Medical College of Pennsylvania 1980.
Board eligible. Group, HMO, academia.
Available.
Subhash S. Pujara M.D., Box 39 IB, Rt.
3, Andalusia AL 36420. B.J. Medical
College (India) 1969. Board certified
(radiology); board eligible (nuclear
medicine). Group, partnership, solo.
Available.
M.S. Vafa M.D., 10378 Gosport, Apt. 9,
St. Louis, MO 63146. Ferdowsi 1973.
Also, internal medicine. Board
certified. Group or partnership. Avail-
able.
SURGERY, GENERAL— Sara A. Case,
M.D., 284 Quinby Rd., Rochester, NY
, 14623. Virginia 1975. Board eligible.
Group — general surgery in moderate-
sized city. Available August 1984.
Ruben J. Delgado. M.D., 7514 Oriental
Tr., San Antonio, TX 78244. Puerto
Rico 1976. Also, vascular surgery.
Board certified. Single or multi-
specialty group or solo. Available
August 1984.
F. Andrew Morfesis, M.D., 7545 Rogers
Ave., Upper Darby, PA 19082. Penn
State (Hershey) 1979. Board eligible.
Available July 1984.
James M. Stem, M.D., 600 Vista Court,
Waynesboro, PA 17268. Jefferson
1958. Board certified. Solo, with free-
dom to practice in broad spectrum of
surgery, including vascular and frac-
tures. Available.
sURGERY, ORTHOPEDIC — SN
Saraiya, M.D., 88-125A 153rd St.. Apt.
4-F, Jamaica NY 1 1432. Baroda (India)
1974. Solo. Available August 1984.
SURGERY, VASCULAR— Ruben J.
Delgado, M.D., 7514 Oriental Tr.. San
Antonio, TX 78244. Puerto Rico 1976.
Also, general surgery. Board certified
(GS). Single or multispecialty group or
solo. Available August 1984.
UROLOGY— Kiritkumar M. Pandya,
M.D., 950 49th St., Apt. 9-A, Brooklyn,
NY 11219. Baroda (India) 1970. Board
eligible. Group, partnership, solo. Avail-
able.
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug.
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding
Write for literature and samples
t BRoWJJfc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 P®®
Likoff Cardiovascular Institute
of
Hahnemann University
offers a course on
Cardiac
IMAGING:
UPDATE 1984
Two-Dimensional Echocardiography
Doppler Ultrasound
Radionuclide Imaging
Newer Techniques
September 6, 7, and 8, 1984
Franklin Plaza Hotel
17th & Vine Streets
Philadelphia, PA 19103
PROGRAM DIRECTORS
Gary S. Mintz, M.D.
Ami S. Iskandrian, M.D.
John P. Panidis, M.D.
Fees
53 95.00 for Physicians
53 25.00 for Technicians
A full refund will be given if cancellation is received
writing prior to August 1, 1984. A processing fee
SI 50.00 will be charged for all cancellations received
writing after that time, and no fee will be refunded
“no shows.”
in
of
in
for
Preregistration
Registration is limited and preregistration is suggested and
should be made with the attached registration application.
Applications should be sent to: Hahnemann University,
School of Continuing Education, Broad & Vine, Philadel-
phia, Pennsylvania 19102. Checks should be made payable
to “Hahnemann University.”
Registration (outside Dominion Ballroom)
Wednesday, September 5, 1984
8:00-10:00 P.M.
Thursday, September 6 through Saturday, September 8, 1984
7:40 A M. to closing
Meeting Place and Hotel Reservations
The course will be held in the Dominion “D” Ballroom
of the Franklin Plaza Hotel, 17th & Vine Streets, Philadel-
phia, Pennsylvania. Hotel reservations should be made
directly with the Franklin Plaza Hotel. A hotel reservation
form will be sent to you upon receipt of your application.
For Further Information
Robert J. Schaefer
Director
School of Continuing Education
Hahnemann University
Philadelphia, PA 19102
Telephone: (215) 448-8263
ACCME
Hahnemann University is accredited by the Accreditation
Council for Continuing Medical Education to sponsor con-
tinuing education for physicians.
AMA
As an organization accredited for continuing Medical
Education, Hahnemann University certifies that this con-
tinuing Medical Education offering meets the criteria for
21 hours in Category I of the Physician’s Recognition
Award of the American Medical Association, if it is used
and compelted as designed.
(please type or print)
Cardiac imaging:
UPDATE 1984
SEPTEMBER 6, 7, 8, 1984
NAME.
ADDRESS.
□ Office
□ Home
CITY.
STATE.
-ZIP.
SPECIALITY/FIELD OF PRACTICE
PHONE
Registration Fee:
□ S3 95.00 Physicians
□ S3 25.00 Technicians
AMOUNT ENCLOSED S.
514
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ME Calendar
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
This list is compiled through the coop-
eration of the Committee on Medical
Education of the Medical Society of New
Jersey, the Academy of Medicine of New
Jersey, the New Jersey Chapter of the
American Academy of Family Phy-
sicians, and the Office of Continuing
Medical Education of the UMDNJ.
NEUROLOGY/PSYCHIATRY
July
2 Behavior Modification
9 1 -3 P.M.— Ancora Psychiatric
16 Hospital, Hammonton
23 (Ancora Psychiatric Hospital and
AMNJ)
5 Basic Neurological Principles for
Neuropsychiatrists
1 2 Significance of Headache in
Clinical Psychiatry
19 Treating the Remarried, Those
Living Together, and Their
Families
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 9 Family and Couple Therapy
12 noon-4:30 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
Aug.
2 Neurological Diagnosis in
Psychiatric Syndromes
9 Attention Deficit Disorder
1 6 The Animal Connection
30 Premenstrual
Syn drome— Psychiatric and
Medical
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
OBSTETRICS/GYNECOLOGY
Aug.
15 Drags, Alcohol, and the Pregnant
Woman
8:30 A.M. -3: 1 5 P.M. — Monmouth
Medical Center, Long Branch
(Div. of Alcoholism, NJ State Dept,
of Health, and AMNJ)
RADIOLOGY
July
2 Basic, Advanced, and Real-Time,
3 Cross-Sectional Sector Scanning
4 9 A.M.-5 P.M. — Sands Hotel,
5 Atlantic City
6 (The National Foundationjor Non
invasive Scanning and AMNJ)
AN ACT OF LOVE
Their own DENIAL that a respected colleague could be IMPAIRED and/or the “con-
spiracy of silence” that makes them unwilling to speak out allows the illness of our impaired
colleagues to progress, sometimes to a fatal outcome.
“Blowing the whistle” on a suffering colleague is indeed an ACT OF LOVE!
Call Us EARLY
We can help CONFIDENTIALLY
IMPAIRED PHYSICIANS PROGRAM
(609) 896-1766
Hot Line . . . (609) 896-1884
'OL. 81— NUMBER 6— JUNE 1984
515
Seeking new patients?
we are
SPECIALISTS
in
PUBLIC RELATIONS
FOR THE MEDICAL PROFESSION
for a confidential interview call
(201) 531-7080
phyllis kessel associates
780 West Park Avenue, Oakhurst, N.J. 07755
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
July 6-8, 1984 and again the weekend of Sept. 9-11, 1984 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
office journal, Acupuncture & Electro-Therap. Res., Int.J. (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Research
Foundation and the Neuroscience Dept, of Long Island College
Hospital, Pharmacology Dept, of The Chicago Medical School.
Also eligible for AMA/CME credit. For information, contact Y.
Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC 10032. Tel:
(212) 781-6262 or (212) WA8-0658, or Saul Heller, M.D., Tel:
(212) 838-7514.
POST-GRADUATE
MEDICAL SCHOOL
FALL COURSE SCHEDULE
AUGUST
8/27-8/31 604 Radiation Physics and Biology
OCTOBER
10/12-10/13 612 Seminar in Ultrasonography
10/13 456 Fine Needle Aspiration of
10/15, 17, 22, 24
10/18-10/21
10/20
10/25-10/28
NOVEMBER
11/17-11/18
11/28-11/30
DECEMBER
12/3-12/6
12/3-12/7
12/10-12/12
12/15-12/16
12/17-12/22
the Prostate Gland
156 Medical Mycology
150 An Eclectic Retrospective
Updated Selections From a Decade of
Dermatopathology Symposia at NYU
550 How to Manage Mental Disorders
in General Medical Practice
611. Imaging of the Head and Neck
(Essex House)
734 New Technologies in Urology
700 Pitfalls in Surgery
350 Neurosurgery NYC/1984
(Grand Hyatt Hotel)
314 Toxicology and Pharmacology
321. Managing Clinical Problems
in the Elderly
733 Basic Review of Pathology &
Radiology for Urologists
603 Computed Tomography
(Grand Hyatt Hotel)
FOR METROPOLITAN AREA PHYSICIANS
9/5-3/13 561 Comprehensive Psychiatry Review &
Recent Advances (Wednesdays 8-10pm)
9/5-12/21 400 Basic Sciences in Ophthalmology
9/12-5/22 420 Basic Sciences in Otolaryngology
1/9-6/19 302 Internal Medicine Board Review
FOR INFORMATION NYU Post-Graduate Medical School
550 First Avenue, New York, NY 10016
(212)340-5295 (24 hr service)
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
For the Investigation of
Problems of Human Infertility
The Foundation provides a complete
diagnostic and consultation service for in-
fertile couples. Investigations are con-
ducted by well-known specialists in con-
junction with consultants in the various
fields of medicine related to infertility.
The Foundation is supported by an in-
house modern laboratory equipped to do
most tests required for diagnosis and
treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
516
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
I
/ETTERS TO THE
Editor
The Medical Director; Baby
Doe; Our New Format
'he Medical Director:
mother Opinion
February 16, 1984
ear Doctor Krosnick:
In the August 1983 issue of The
ournal. you published a letter from
r. Charles Harris which could be
lisleading and is in need of elari-
cation. In regard to his statement.
The next phase in hospital rela-
ons is the interpolation of a medi-
al director between the adminis-
ation and the medical staff,” the
(pinions and issues he raised are
itelligent and pertinent. However, I
m concerned with the reactions of
our readers.
Statements such as: “A doctor is
'nly a doctor when treating patients:
jerhaps a very good secretary could
je trained for the job: our talent is
quandered uselessly in nonprodue-
ve administrative chores; a medical
egree (becomes) subordinate to an
dministrative office,” seriously are
lisleading. Realistically, what sadly
> lacking is understanding the role
of the doctor/administrator. Having
been in practice over three decades
and a doctor/administrator for over
one decade, I emphatically can state
that there is “intrinsic beauty” in
improving the delivery of health care
and the quality of health care
through administrative functions. A
"good" secretary is a difficult person
to define and. of course, could never
subsume his role, especially the peer
relationships. The medical degree
need not become subordinate to an
“administrative officer.” Either of
two relationships commonly prevail.
Specifically, there either can be
absolute or cooperative control. The
physician notifies the adminis-
tration what policy is best and the
lay people try to implement it; or ad-
ministration suggests a policy or
project or procedure to the phy-
sician for his professional input
which always is respected.
I agree with Dr. Harris that the
medical director must react to PRO.
PRO monitors utilization— again,
realistically the monitor must be
monitored. Obviously, with the large
sums of money and time spent, care-
lessness and inefficiency cannot be
tolerated. Who will make policy?
Who will make the final decisions?
Possibly a three-member committee
could do the job: the medical direc-
tor, a representative of the hospital
administration, and a representa-
tive of the public (either a Chamber
of Commerce or labor union individ-
ual) who could alternate on a yearly
basis. Possibly, an additional mem-
ber from the local government could
be added. The committee would
dilute the authority from one person
(medical director) to a collective
body.
Finally, our profession always has
been proud of its moral integrity as
a bulwark against the onslaught of
economic forces, e.g. an employer
paying a salaiy, the government pay-
ing for drugs, medical equipment,
and office visits. Already, within our
government it is worthy of note that
the judicial branch has recognized
the pre-eminence of medical ethics
in governing physicians’ behavior.
The Supreme Court of the United
States, in a recent decision, stated
that physicians employed by the NY
State Medicaid Program (Blum v
Yaretsky, 1982) acted in accordance
with the canons of ethics estab
lished within their own professional
groups, rather than under rules of
conduct dictated and imposed by
the state. In a discussion of this rul-
ing in the February 24, 1983, issue
of the New England Journal of
Medicine it was pointed out that the
court assumed, "That the physi-
cians would act with personal integ-
rity and only on behalf of the best
interests of each patient.” Let us also
assume that the medical director
will remain true to the canons of ex-
isting professional ethics.
Please understand the above
bears no relation to the attitude or
opinions of the Division of Medical
Assistance in the state of New Jer-
sey. I am writing as an individual
and terminating my employment
with the Division on March 1, 1984.
(signed) Charles J. Grubin, M.D.
Baby Doe
February 28, 1984
Dear Doctor Krosnick:
I read your excellent dissertation
on the Baby Doe controversy in The
Journal of the Medical Society of
New Jersey.
I found it to be very well presented
and a reasonable approach to the
solution of this difficult problem.
Unfortunately, the lawyers prob-
ably won't let us provide a solution
as simple and practical as you sug-
gested.
We probably will be using your
article as the basis for one of our
ethics conferences. I thought you
might like some feedback about the
article.
(signed) John C. Brogan, M.D.
Our New Format —
They Like It
March 18, 1984
Dear Doctor Krosnick
Just want to congratulate you on
the new format of The Journal. It is
much more readable, clear in the
summaries, and generally a fantas-
tic improvement.
Best wishes.
(signed) John A. Sakson. M.D.
March 23. 1984
Dear Doctor Krosnick:
Congratulations on (he new for-
mat for The Journal. 11 is clean, con-
cise. and veiy attractive. Best wishes,
(signed) Stanley S. Bergen. Jr., M.D.
President, UMDNJ
OL. 81— NUMBER 6— JUNE 1984
517
BOOK REVIEWS
The Electrocardiogram in
Infants and Children;
Evaluation and Decision
Making for Health Services
Programs; New Frontiers
in Mammary Pathology;
Fundamentals of
Immunology; Progress in
Cardiology; Sports
Medicine
The Electrocardiogram
in Infants and Children:
A Systematic Approach
Arthur Garsorr Jr., M.D. Philadel-
phiau PA, Lea & Febiger, 1983. Pp.
421.
In the preface, the author
emphasizes the impact the emerg-
ing science of electrophysiology has
had upon electrocardiography. The
first six chapters cover anatomy,
physiology, derivation, and defi-
nition of the ECG. The middle chap-
ters deal with effects of altered
thoracic anatomy, chamber enlarge-
ment, interventricular conduction
disturbance, and, to a lesser degree,
ischemia injury, and infarction.
There is an excellent summary of ef-
fects of systemic alterations on the
electrocardiogram, e.g. antiarrhyth-
mie drugs, anesthetics, neuromus-
cular disorders. The latter part of the
book is devoted to arrhythmias with
emphasis on recognition and
etiology when known. Ladder dia-
grams are used as the major graphic
display for analyzing rhythm and
conduction variations. Legends for
ligures tend to be concise with ex-
planations easy to comprehend. The
reader is not left to infer the author’s
intent in a given diagram. Clinical
relevance frequently is stressed. The
last chapter discusses artifacts
which may occur during ECG read-
ing and may lead to errors of inter-
pretation. A method for system-
atically recognizing artifacts is de-
scribed.
The appendices are used to sum-
marize important ECG charac-
teristics which vary with age, e.g. PR
interval, QRS duration in V5, R/S
ratio in V6.
The index is well organized and
allows rapid location of subjects cov-
ered in the text along with desig-
nations identifying tables and fig-
ures.
A particularly appealing feature to
this book is the question-and-
answer section following each
chapter. The author stimulates the
reader to assess his retention of key
points. These questions are well
selected, clinically relevant, and just
as easily could be found on a certify-
ing examination.
This book was very readable. It can
be used to teach students of elec-
trocardiography irregardless of
background. It also can be an excel-
lent reference text for the journey-
man electrocardiographer.
Robert M. MacMillan, M.D.
Evaluation and Decision
Making for Health
Services Programs
James E. Veney and Arnold D.
Kaluzny. Englewood Cliffs, NJ,
Prentice-Hall, Inc., 1984. Pp. 302.
($26.95)
For a practicing physician, this
book was boring to read, and told me
more about “methodological tech-
niques” and "conceptual models”
than I cared to know. It defines
evaluation as “the collection and
analysis of information by various
methodological strategies to de-
termine the relevance, progress, effi-
ciency, effectiveness, and impact of
program activities.” Relevance refers
to whether a program is needed. I
seriously wonder about the rel-
evance of this book. It probably will
find a place in the library of health
planners, managers, developers, and
statisticians (the ample bibliogra-
phy lists more articles on econo-
metrics than on health care).
The most interesting is chapter
15, which analyzes cost benefit and
cost effectiveness, using the opening
of a satellite ambulatory clinic and
the addition of a 20-bed pediatric
wing to a county hospital as illust -
tions. The hardest chapter to und<
stand is chapter 8 because it is
full of statistics and meaningle;
equations. It takes 14 pages to con
to the conclusion that “the reducl
speed limits nationwide apparen
have had some impact on traT
deaths on a national basis.”
The authors admit that “monitdj
ing, at best, is inconvenient;
worst, it uses up time and resourci
that providers feel should be devot;
to ‘practice.’ ” In discussing surv i
research as an evaluation strate^
the most interesting illustration
the comparison of fee-for-servi
group practices with prepaid prc
tiees: the latter spent 10 to 15 pt
cent less time serving patients ar
earned $4,000 to 6,000 less.
Robert Sigmond, one of the eat >
pioneers in health planning,
quoted as saying that hospital pla;
ning decisions “are not made ov
‘hard facts,’ they are made over ‘ha
liquor.’ ” This book would have be<jl
more interesting if it had been wr
ten the same way.
John S. Madara M.
New Frontiers in
Mammary Pathology
K.H. Hollmann and J.M. Verlt
(eds). New York, NY, Plenum Pres
1983. Pp. 455. ($55)
This book represents a record <
papers presented at the second Syr
posium of the International Socie
Against Breast Cancer, held in Pari
December 7 to 10, 1981. Partic
pants were invited guest seientis
from Belgium, Brazil, France, Gre;
Britain, Greece, Italy, Japan, Porti|
gal, Spain, Switzerland, Yugoslavi
and the United States.
The supposed causative factors <
breast cancer were evaluated t
specialists; genetic, hormonal, mill
factor, (mammary tumor virus) e:
pecially as studied in mice, are d<
scribed. The existence of a huma
mammary tumor virus could not t
demonstrated.
It would appear that mammai
carcinogenesis is of multifactor;
origin and that inherited factors ir
creasing the susceptibility to breaJ
cancer play an important part. Th
existence of cancer genes now i
under experimental study. Breas
cancer is not a single process be
rather a cascade of events.
518
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
Hyperplastic nodules are likely
Eemalignant lesions and represent
1 important step toward in situ
rcinoma and infiltrating cancer.
acent efforts in the research field
live focused on: tumor cell markers,
lirmone receptors, angiogenesis,
•ostaglandins, thermography,
ammography, aspiration cytology,
id immune processes.
Digestion of the volume gives one
e impression that despite all the
uergy that has been devoted to the
object we actually do not know the
i use of breast cancer in either sex
Lr do we have, as yet, an absolute
Method of therapy.
The book is produced by photo-
i py methods. The illustrations are
; cep table. Printing errors were
nted on pages 7. 10. 101, 142, 192,
1)0, 250 and 257; page 367 the word
‘and" is misspelled.
Llnterest in the human breast has
listed probably from the days of
Pin and Abel. This volume will con-
nue that trend and should be read
I' their progeny.
T. K. Rathmell, M.D.
]
I undamentals of
nmunology, 2nd Edition
\ientin Myrvik, Ph.D., and Rnssel
I Weiser, Ph.D„ (eds). Philadelphia,
jf. Lea & Febiger, 1984. Pp. 510.
lustrated, ($24.50)
This attractive hardcover and
ull-bound book on the rapidly ex-
inding body of knowledge of im-
lunology truly is remarkable for its
ill content and its low price. In ad-
(tion to two of its editors who also
<e contributors there are seven ad-
(fional authors— all but three of
|hom come from the Bowman Gray
I hool of Medicine in Winston-
llem, North Carolina. The other
|ree authors are from Hamburg,
’jest Germany, University of Geor-
Athens, Georgia, and the College
i William and Mary in Gloucester
l int, Virginia, respectively.
This book is comprised of 25
< apters, two appendices, and 14
I;
»L. 81— NUMBER 6— JUNE 1984
pages of a very complete index.
Chapter 1 is entitled “Introduction
to Immunology” and includes his-
tory, development, and scope plus
terminology: these are interesting
and well done. The final chapter is
entitled “Immunity to Animal Para-
sites” and the information is pure
1984. All important subjects in im-
munology are covered in the inter-
vening chapters. There are many
charts and lists and a moderate
number of electromicrographs. The
latter are very clear and in focus. The
chapter on the complement system
is superb.
The authors recommend this text
for medical and veterinary students.
I go beyond this and state it is
strongly recommended for pathology
and medical residents plus all prac-
ticing physicians who want to keep
current in this fascinating and very
important field.
Hugh F. Luddecke, M.D.
Progress in Cardiology ,
Volume II
Paul N. Yu, M.D., and John F.
Goodwin, M.D., (eds). Philadelphia,
PA, Lea & Febiger, 1983. Pp. 195.
($30)
Progress in Cardiology, Volume II
contains nine chapters that deal
with a variety of cardiovascular
problems.
Each chapter is composed and
written by groups of distinguished
scholars in the field of cardiology.
The subjects reported upon are
timely and cover most of the
methods and laboratory techniques
in noninvasive measurements:
pulmonary physiology; prostaglan-
dins; hypertension and heart failure
relations; the role of catecholamines
in hypertensive and congestive
cardiomyopathy; pharmacology in
pulmonary circulation; relationship
between smoking and heart disease;
and the pathophysiology and ther-
apy of cardiogenic shock.
A fact this reviewer found very im-
pressive was the agreement among
all authors of the direct correlation
between cigarette smoking and
cardiovascular mortality, morbidity,
and the so called “sudden death syn-
drome” of myocardial infarctions.
The essays, or lectures as they
seem, are easy to read and un-
complicated to follow. References are
plentiful at the end of each chapter.
This text is recommended for all
medical libraries and certainly to all
cardiologists and family physicians.
Harry M. Poppick, M.D.
Sports Medicine: Health
Care for Young Athletes
American Academy oj Pediatrics.
Evanston, IL, 1983.
Utilizing multiple authors and
consultants, this book is a compila-
tion of information concerning all
aspects of sports medicine as it
pertains to the child and adolescent
athletic participant. Each chapter
was written by an expert in the field
and then reviewed by a panel of con-
sultants to insure accuracy and
completeness of information.
Chapters on counseling the fam-
ily, physical maturation, prepartici-
pation health examination, and
assessing athletic potential are par-
ticularly useful for the pediatrician
and family physician in dealing with
the young athlete and his/her fam-
ily, and advising them regarding
participation in various sports best
suited for each child, particularly
those with specific health problems.
The remainder of the book covers
the many health and injury prob-
lems encountered in sports partici-
pation, and there are chapters on
drugs, nutrition, and thermoregula-
tion to include fluid and electrolyte
balance.
Printed in paperback fashion, the
book has only a few illustrations, but
there are many tables, and the book
is indexed. Overall, the book is well
worth purchasing for reference by
any physician dealing with young
persons active in sports.
Christine E. Haycock, M.D.
Obituaries
Drs. Bochenek ; Buckley;
Deuell; Frank; Glick;
Harrington; Jacobus;
Olson; Reich; Rosenberg;
Stewart; and Vanderbeek
Dr. Joseph P. Bochenek
On March 17, 1984, a senior mem-
ber of our Morris County compo-
nent, Joseph Paul Bochenek, M.D.,
died at his home. Bom in Poland in
1910, Dr. Bochenek received his
medical degree from the University
of Nancy, France in 1939. Until
1948, he lived in England and served
in the British Army as a paratrooper
in World War II. Dr. Bochenek emi-
grated to the United States and set
up a practice in family medicine in
Netcong. After 20 years he closed his
office and served as emergency phy-
sician at Dover General Hospital. Dr.
Bochenek was a member of the
American Medical Association and
of the Academy of Emergency Phy-
sicians.
Dr. Jeremiah L. Buckley
At the age of 83, Jeremiah Law-
rence Buckley, M.D., died on April
17, 1984. Bom in 1900, Dr. Buckley
received his medical degree from the
University of Vermont Medical
School in 1926. An internist for 42
years. Dr. Buckley was on the staffs
of Saint Barnabas Medical Center,
Newark, St. Mary's Hospital, Passaic,
and Clara Maass Medical Center,
Belleville. He retired in 1968. Dr.
Buckley was a member of our Essex
County component and of the
American Medical Association.
Dr. William D. Deuell
At the age of 74, William D. Deuell,
M.D., died on March 31, 1984. Bom
in Allendale, Dr. Deuell was gradu-
ated from Columbia University’s Col-
lege of Physicians and Surgeons in
1934. Prior to his retirement in
1971, he had practiced general
medicine in Hackensack for 35
years. Dr. Deuell had been on the
staff at Hackensack Medical Center
for 32 years. He was a member of the
American Medical Association. Dur-
ing World War II, Dr. Deuell served in
the medical corps of the United
States Navy, attaining the rank of
lieutenant commander.
Dr. Perry Frank
We just have learned of the death,
on February 9, after a long illness, of
Perry Frank, M.D. Bom in 1914, and
a native of Egg Harbor City, Dr.
Frank received his medical degree
from the University of Pennsylvania
School of Medicine in 1938. Prior to
his retirement two years ago be-
cause of ill health, he had been a
general practitioner in Egg Harbor
City for 40 years. During World War
II, Dr. Frank served in the medical
corps of the United States Navy for
five years, attaining the rank of cap-
tain. He was a member of the Ameri-
can Medical Association.
ing World War II, Dr. Glick served
the medical department of the Am
of the United States.
Dr. John H. Harrington
At his retirement home in Coc
Beach, Florida, John Heniy He!
rington, M.D., member of our Mon
County component, died on Mar
10, 1984. A native of Buffalo, Nf
York, Dr. Harrington was graduat
from Cornell University’s School
Medicine in 1927. He practiced o
stetrics and gynecology in Rockaw
until his retirement in tl
mid-1970s. Dr. Harrington served
the United States Air Force durii
World War II, attaining the rank
major. He was a member of tl
American Medical Association anc
Fellow of the American College
Obstetricians and Gynecologists. E
Harrington was 82 years old at tl
time of his death.
[
Dr. Raymond E. Jacobus
Word has been received of t
death on January 27 of Rayrnoi
Earl Jacobus, M.D., a member of o
Monmouth County componer
Bom in 1920, Dr. Jacobus w
graduated from the School of Mec
cine at Syracuse University in 194
He established a practice in o
stetrics and gynecology in Freehol!
and was affiliated with Jersey Sho
Medical Center, Neptune. E
Jacobus was board certified in o
stetrics and gynecology, a Fellow
American College of Obstetriciaj
and Gynecologists, and a member
the American Medical Associatioi
Dr. Bernard Glick
A senior member of our Bergen
County component, Bernard Glick,
M.D., died March 31, 1984, at
Passaic General Hospital. Bom at
the turn of the century in New York
City. Dr. Glick received his medical
degree from the University of
Maryland’s School of Medicine in
1927. He was a general practitioner
with an office in Lyndhurst until
1970 when he established a practice
in Passaic. Dr. Glick had been on the
staff at Hackensack Medical Center,
Passaic General Hospital, and South
Bergen Hospital, Hasbrouck
Heights. He was a member of the
American Medical Association. Dur-
Dr. Vendela E. Olson
Vendela E. Olson (Rucker), M.D.,
member of our Bergen County cor;
ponent, died on March 5 at the aj
of 78. Dr. Olson was graduated fro
the University of Minnesota’s Seho
of Medicine in 1941, and also w;
qualified in the field of hospital a>
ministration. She was director
medical services at St. Luke’s Hosp
tal. New York City, following hi
work as an anesthesiologist
Hackensack Hospital. Dr. Olson a h
was the first president of the Bergt
and Passaic Lung Association uni
following their consolidation, ar
was elected to the American Lui
Association of New Jersey’s Hall
Fame in 1982.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
520
r. Samuel B. Reich
M the venerable age of 8 1 , Samuel
iswell Reich, M.D., a member of our
rgen County component, died at
5 retirement home in Lantana,
jrida, on April 3, 1984. Bom in
w York City, Dr. Reich received his
’dical degree from New York Uni-
rsity School of Medicine in 1927,
d established a practice in
rdiology in Hackensack. He be-
ine head of the cardiology depart-
mt and of the cardiac clinic at
rgen Pines County Hospital, Para-
js, and was on the staff at Paseack
iley Hospital, Westwood, Fair
wn Memorial Hospital, and
isbrouck Heights Hospital. Dr.
ich was a Fellow of the American
liege of Physicians and of the
lerican Geriatrics Society, and
o board certified in internal medi-
le. He was a member of the Ameri-
la Medical Association and a past
?sident of the Bergen County
'dical Society.
Dr. Hyman Rosenberg
Retired since 1974, Hyman Rosen-
berg, M.D., died in West Palm Beach
Florida, on March 1, at the age of 66.
A native of Philadelphia, Dr. Rosen-
berg received his medical degree
from Hahnemann Medical College
and Hospital, Philadelphia, in 1942.
He established a practice in internal
medicine in Camden, and was af-
filiated with West Jersey and Our
Lady of Lourdes Hospitals in
Camden, and was an instructor at
Hahnemann Medical College. Dr.
Rosenberg was board certified in his
specialty and was a member of the
American Medical Association.
Dr. Irving J. Stewart
Bom at the turn of the centuiy,
Irving Jaggard Stewart, M.D., a
member of our Gloucester County
component, died on March 19, 1984.
A native of Camden, Dr. Stewart was
graduated from Jefferson Medical
i
I
'
College of Philadelphia in 1925, and
the next year established a practice
in general medicine in Swedesboro.
Aside from 50 years of family prac-
tice, he held various municipal of-
fices in his community, serving as
police surgeon, school physician,
and president of the board of health.
Dr. Stuart W. Vanderbeek
We just have learned of the death
on September 9, 1983, of a senior
member of the Bergen County com-
ponent, Stewart W. Vanderbeek,
M.D. A native of New Jersey, bom in
1895, Dr. Vanderbeek received his
medical degree from Jefferson Medi-
cal College of Philadelphia in 1921.
Prior to his retirement in the
mid-1970s. Dr. Vanderbeek prac-
ticed general medicine in Engle-
wood, and was an attending at
Englewood Hospital. He was a mem-
ber of the American Medical As-
sociation.
L. 81— NUMBER 6— JUNE 1984
521
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEV
i|
T° Career Oriented Fm
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Can you accept th l er9encV MediCine
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GROUP PRACTICE
OPPORTUNITIES
BC/BE Family Practitioners for expanding
federally qualified HMO, serving 36,000
members from three delivery sites in Cos-
mopolitan South Jersey area. Congenial
staff of 30 full-time physicians, and 75 to 100
contracting specialists covering all dis-
ciplines. Excellent hospital facilities. Medical
school affiliation. Choice of pleasant living
conditions in suburban, rural, or semi-rural
communities. Superior schools. Easy access
to Philadelphia (15 minutes), New York City
(90 minutes), Jersey Shore (60 minutes),
Jersey Pine Barrens (20 minutes) and
Pocono Recreation Area (2 hours). Com-
petitive salary and comprehensive benefit
package.
Send Curriculum Vitae to Kenneth M.
Carroll, M.D., Executive Vice Presi-
dent/Medical Affairs, Health Care Plan of
New Jersey, 165 Old Marlton Pike, Medford,
New Jersey 08055.
Director of Emergency Health Services
Public Health Physician required to direct the statewide activities of an Emergency Health Services
unit in the Division of Local and Community Health Services, New Jersey State Department of Health.
This position reports to the Assistant Commissioner in charge of the Division and is assigned direct
responsibility for the direction and supervision of emergency health services activities including
assurance of an effective working relationship with basic life support ambulance services, advanced
life support services, law enforcement and public safety agencies, hospital emergency departments
and critical care facilities, local health departments, and other community agencies, organizations and
individuals.
The Director is charged also with responsibility for assuring that emergency transport facilities
meet minimum standards, that certain hospitals are prepared to provide critical care services, that
a curriculum is established for the training of health care personnel who are engaged in emergency
care (physicians, nurses, paramedics, EMT’s, law enforcement personnel); that emergency care is
monitored carefully, and that New Jersey’s local health departments coordinate their programs with
emergency health care services throughout the State.
As one of five doctorate prepared Service Directors in the Division this position has direct access
to the Department’s senior executive staff. The annual budget totals $1 million. Requirements for this
position are graduation from an accredited medical school; a master’s degree in public health from
a recognized school of public health and seven years of professional experience in public health
including at least four years in the management of a statewide or regional community health program
preferably with emergency medical services experience and two years of direct clinical experience
in emergency medicine. This is an unclassified position with an annual salary range of $41,080.08
to $55,460.60.
Interested candidates should contact:
Dr. Leah Z. Ziskin, M.D., M.S.
Assistant Commissioner
Local & Community Health Services
N.J. State Department of Health
120 So. Stockton Street
CN 364
Trenton, NJ 08625
PL. 81— NUMBER 6— JUNE 1984
523
PAGE REFERENCES
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Financial
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445, 467, 468
441, 464
514, 516
467, 484-486, 524
Cover II, 464, 467
523, 524, 525
516
524, 525
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I
Director of Local Health Development Services
The New Jersey State Department of Health has recently undergone an expansion of its local health
department interest and funding. A new Division of Local and Community Health Services has been created.
This is one of the seven Divisions of the Department which cover Laboratory, Epidemiology, Substance Abuse,
Health Facility Development, Administration, and Health Inspection Services.
A Public Health Physician is required to direct the activities of a recently created pivotal unit to be known
as Local Health Development Services in the new Division of Local and Community Health Services. Augmented
local-state communication services are planned through a combination of ombudsmanship, regular planned
meetings, and immediate notification of health emergencies. Consultation and development services are being
expanded through liaison of local health agencies with existing Adult, Emergency, Environmental, and Parental
and Child Health Services of the Division.
The successful candidate will report to the Assistant Commissioner who heads the Division, and will have
direct responsibility for a variety of support services for New Jersey’s 117 local health departments. Such support
activities include: health aid services in the form of direct local health funding, the development and monitoring
of compliance with minimum performance standards, the coordination and maintenance of local health reporting
data, and evaluation and training services for local health departments.
This is an extremely critical position with widespread responsibilities for maintaining a partnership between
local health departments and the State Health Department. The new unit’s annual budget is over $4.5 million.
This position requires a medical degree, a Master’s degree in Public Health from an accredited school of
public health and seven years of experience in the broad field of public health including at least four years of
progressively responsible managerial experience in a regional or statewide public health program. Local health
administration experience is desirable. Salary range is from $41,080.08 to $55,460.60, with actual annual salary
based on experience and qualifications.
Interested candidates please contact:
Dr. Leah Z. Ziskin, M.D., M.S.
Assistant Commissioner
Local & Community Health Services
N.J. State Department of Health
120 So. Stockton Street
CN 364
Trenton, NJ 08625
524
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CLASSIFIED ADVERTISEMENTS
GENERAL PRACTITIONER— Semi re
ired, age 55, desires industrial, pharma-
eutieal or similar position. 201-
45-4339.
5ENERAL PRACTITIONER— Ex
)erienced general practitioner, M.D.
Paris) 1957. Seeking position in New
Jersey— general medicine preferably.
Wailable. John Fredericks, MD, 170-20
Jenley Road, Jamaica Estates, NY, NY
1432. Telephone 212-658-1675.
NTERNIST — Board eligible, general in-
emist with extensive emergency room
xperience. Seeking group practice of
ntemal medicine or emergency room
>osition. Northern NJ area Available July
984. please call 212-645-4616, Steven
Volinsky, MD. Curriculum vitae and ref-
rences available upon request.
•EDIATRICIAN — Seeks part time pos-
tion, Pediatric clinic or office. Middle
ige, board certified, planning to sell pri-
vate practice. Prefer Monmouth or Ocean
bounty. Willing to work nights and week-
nds. Write Box No. 73, JMSNJ.
•HYSICIANS — Registered Dietitian
vailable to provide nutrition, diet and
jreight-eontrol counseling for your pa-
tients in the Trenton-Prineeton-New
Brunswick area your office or mine. Call
109-737-2160.
•HYSICIANS REFERRAL— Registered
Dietitian available for nutritional eoun-
eling, physican referral only. New
Irunswick area Weekend hours and
tome visits can be arranged. A Health-
lirays provider. 201-257-3773.
1EEDED PHYSICIANS — For successful
Veil known walk-in medical office center,
Central NJ. Full and part time, skilled
ersonable American-trained MDs. Send
:V to E.V. McGinley, MD, 1005 N. Washi-
ngton Avenue, Green Brook, NJ 08812.
•RACTICE FOR SALE— General Medi-
ine Practice for sale. Central, NJ, 45
(ninutes from NY. Blend of office-nursing
tome patients. Low overhead. Write Box
Jo. 79, JMSNJ.
PRACTICE FOR SALE — Twenty-year
)ld, solo, general practice in South-Cen-
ral New Jersey. 20 minutes from Phila-
delphia and 1 Vi hour from New York City.
j3usy, efficient, high net. Just negotiated
i seven year assignable lease for a new
)ffice in the same building. Lovely
suburban area with top-rated school sys-
ems. A good place to live and work. Leav-
ng to go sailing. Write Box No. 86,
JMSNJ.
PRACTICE FOR SALE— OB/GYN, im-
mediately in Northern Monmouth Coun-
ty, near two accredited hospitals, in ap-
pealing residential community. Will in-
troduce. Call 201 264-7763.
FOR SALE or RENT — Fully equipped
and furnished medical office building in-
cluding patient’s records. Comer lo-
cation on main street, Kearny, NJ. Call
after 8 p.m. 201-746-1709.
FOR SALE or RENT — For immediate oc-
cupancy new, modem, energy efficient
rental 500 to 2,000 square feet available.
31,000 residents within three mile
radius. Close to Philadelphia Atlantic
City; in Central New Jersey shore area
Internists and specialities needed. Ideal
for main/satellite office. Call 201-
350-1008.
FOR SALE — Equipment. Blue examin-
ing table, White instrument cabinet,
Four attached Black chairs and table.
Doctor’s walnut desk. Miscellaneous.
Please call 991-6250 or 435-4209.
FOR SALE — Country Estate. For Great
living or investment. 74 acres Catskills,
100 miles from NYC. Magnificent view. 9-
room house, large living room with fire-
place, dining room, 4 bedrooms, 3 baths,
superb kitchen with Jenair and micro-
wave. Playroom, large storage cellar, 4
room guest cottage, 4 room guest house,
4 car garage, large bam, trout pond, bass,
skiing, snowmobiling, deer, wild turkey,
white water canoeing nearby. $250,000
antiques and furnishings may be separ-
ately negotiated only with estate
purchase. Isabell Sander 914-482-5191.
FOR LEASE — Attractive, modem medi-
cal building, Morris Avenue, Union
Center, Union, NJ. Office for lease. 750
square feet, large, private adjoining park-
ing lot, 1st floor, no steps . . . will build to
suit. Phone 201-688-2480.
OFFICE SPACE — Professional office for
rent. Approximately 710 square feet.
Near Dover General Hospital, near
Routes 80 and 46. Morris County, NJ.
Telephone 201-366-2557.
OFFICE SPACE — Professional office
space for rent. Millbum prestigious
building. 775 square feet, on-site park-
ing, on bus route. Call 201-731-1900.
OFFICE FOR RENT — Professional office
for rent, furnished, located in the Iron-
bound Section of Newark. Available July
1984. Call 201-762-6781.
OFFICE SPACE NEEDED— Licensed
Clinical Psychologist with child, adoles-
cent, and adult practice would like to
rent office space in the Madison,
Florham Park, or Morristown area Must
have own office. Professional building
preferable. Please leave message at
201-267-4997 or write to: Merrilea
Brunell, Ph.D., 21 Mt. Kemble Ave„ Mor-
ristown, NJ 07960.
OFFICE TO SUBLET — Medical office to
sublet in professional building in
Deptford (Woodbury) area. 609-
853-8720.
OFFICE TO SHARE — Bergenfield, cen-
trally located professional building. Park-
ing, furnished, 900 square feet, $450.
Five minutes from hospitals. Summer
1984. Write or Call Ronny Meier, MD, 297
S. Washington Ave„ Bergenfield, NJ
07621. Phone: 201-385-8350.
OFFICE TO SHARE — Central Denville,
in recently renovated medical building.
Furnished, equipped, utilites included.
Ample parking, public transportation.
For information: 201-625-9411.
OFFICE TO SHARE/RENT— Spacious,
furnished 600-1500 square feet, ample
parking. Hazlet-Holmdel area close to
hospital. Call 201-264-7763.
OFFICE TO SHARE/RENT— At two lo-
cations in Hudson County. Furnished,
parking, close to hospitals and transpor-
tation, all utilites included. 201-
864-7172.
OFFICE TO SHARE — Morristown, cen-
tral location. Near hospital, fully
equipped, newly decorated. All utilities
included. Ample parking available. Near
public transportation. Available immedi-
ately 201-267-2555.
OFFICE TO SHARE— Westfield, central
location, near hospital, fully equipped, at-
tractively decorated. All utilities included.
Ample parking available. Near public
transportation. Available immediately
201-267-2555.
VACATION — Martha’s Vineyard, Mass. 3
bedroom house, free tennis, fresh and
salt ponds. Available for rent by week,
month or season. For information call
201-625-941 1.
AUTUMN FOLIAGE — Photography sem-
inar at a country inn, Northern Vermont,
September 19-24, 1984. CME credit. Cal!
or write: John L. Krause, Jr., MD, South
Jersey Medical Center. Cherry Hill, NJ
08034. 609-795-7766.
tATE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
WORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
lumbers, hyphenated words. Count name and address as five words, telephone number as one word, and "Write Box No. 000,
/o JMSNJ" as six words. COPY DEADLINE: Fifth of preceding month.
0L. 81— NUMBER 6— JUNE 1984
525
Specially designed home faces N.Y.C. skyline
Cedar Grove, N.J.
This 17 year old address offers many intrinsic valuable intangibles.
Set high on a bluff, an unparalleled ultra spectacular New York City
Skyline (12 mi. distant) unfolds in never ending viewing thrills. 17 rooms
(5 bedrooms) 10 baths, Cathedral living room, 24 x 40 game room,
Norwegian sauna, 35 foot Jacuzzi health pool, huge outdoor swimming
pool with children’s wading pool, two and one half acre plot includes
subdivided plot and a host of other must see features. Widow must
sell at a drastically reduced price which is half of the reproduction cost
$675,000. Private low interest financing. Brokers invited.
Savino Agency— 251 Ridge Rd., Lyndhurst, N.J. 201-438-3120
I
TWO MEDICAL SUITES
Available August— Livingston Avenue (Doctors’
Row)— New Brunswick, NJ. Both suites fully
carpeted, sink, closets in each room. One suite
has X-Ray room with equipment.
For Information Please Call
201-828-2715
Need A Temporary Physician?
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own during: vacations, CMEs, recruiting, clinic
start-up or other absences.
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For further information about temporary coverage
or locum tenens practice opportunities, call:
£2 CompHealth
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WILSON ROSS, Regional Administrator
244 East Hanover St.
Trenton, NJ 08608
Telephone: 609-392-1111
DOCTORS!
We need your service to complete a brand-new,
elegant, boutique-style shopping and office
center. Several medical offices within center.
Great location in upscale, affluent, growing area.
Just 5 miles from both Middlesex General Univer-
sity Hospital and St. Peters Medical Center. Hid-
den Lake Towne Center, Off Rt. 27, No. Bruns-
wick.
For Information Please Call
(201) 846-5700
ADVERTISEMENT
Multi-specialty Surgical Group in New Jersey
has opportunities for: Vascular surgeon, urol-
ogist, orthopedist, pediatric surgeon, head
and neck surgeon. Must have or be eligible
for New Jersey license. All operating ex- <
penses paid. Write to New Jersey Physician
Placement Service, Box 252, Fair Lawn, New
Jersey 07410.
SPECIALISTS WANTED IN PERU
Pediatricians — Gynecologists — General Surgeons to
spend two or three weeks in Peru teaching and working
with local specialists. Must know some Spanish. Room,
board and gratitude provided. Pay own airfare. Write:
PROJECT PERU, INC.
c/o Robert Zufall, M.D.
64 Baker Ave.
Dover, N.J. 07801
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
526
The Journal
the Medical
Society of
New Jersey
JULY 1984
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NUMBER 7 — JULY 1984
527
July 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 766
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hlrseh, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Coilingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe. M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia, M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
Henry J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
Publication Committee
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosniek, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/ Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. SpindeU, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
ournal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) excep
rthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of Ne1
wo Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA, by the Hughes Printin
rum per of issues 964. Member’s subscription ($10) is included in Society dues. Rates for nonmember
teA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, Tw
ss Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and addition!
entry office. Copyright 1984 by the Medical Society of New Jersey.
528
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation ,
in this unique P.A.C.E. program, '■ a
for more information please call jfi
(201) 456-3200.
The card that you can count on ...
®Blue Shield
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^T1
Features
532 Membership Newsletter
537 Professional Liability Commentary
54 1 Editorial Special: The Academy of Medicine of New Jersey Awards
543 Editorial
545 Hospital Governing Boards
Contributions
549 Out-of-Hospital Births: A Survey of Parents
M. Gregory, M.D., R.B. McDonough, R.N., L. Maciorowski, R.N.,
E. Miller, M.S., Trenton
557 Case Report: Alcoholic Cardiomyopathy
I A. Gaspar, M.D., Englewood
563 Case Report: Tracheoesophageal Fistula and Arteriosclerotic Aortic
Aneurysm
R. Schiffman, M.D., Camden
569 Clinical Note: Guided Blind Endotracheal Intubation
J.J. Choi M.D., M. Potian, M.D., E.Y. Yoo, M.D., W. Wa, M.D., Newark
573 Clinical Note: Adverse Drug Reaction after Administration of
Influenza Vaccine
R. Solomon, M.D., J. Morlino, D.O., M. Martucci, R.N., D. Ney, R.N., Union
576 Medical History: Conversations in Medicine
A. Weisse, M.D., Newark
58 1 Current Nutrition: Progress in Food Allergy and Food Sensitivity
R.N. Podell, M.D., New Providence
586 JEMPAC Update
W.E. Ryan, M.D., Pennington
Doctors’ Notebook
589 Trustees’ Minutes: May 2, 1984, and May 6, 1984
590 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
59 1 Practical Solutions to Common Transfusion Problems
594 Physicians Seeking Location in New Jersey
MSNJ Departments
597 CME Calendar and Information
604 Letters to the Editor
605 Book Reviews
607 Obituaries
608 Information for Authors
On the Cover: Attendees at
AMNJ’s Awards Dinner received
an original limited edition print
by Richard Kemble which is a
semi-abstract impression of the
oak tree on Princeton Battlefield.
Kemble was inspired by Japanese
calligraphy.
New Jersey
X ^
yj
II
jQ
WffiZ'
IpTfcv
*'•***
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
530
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81— NUMBER 7— JULY 1984
531
Membership
Newsletter
THE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 1
DRGs AS AN AUDIT TOOL
There has been considerable debate on the effective-
ness of DRGs as a reimbursement methodology. At a
Washington meeting of the American Society of
Anesthesiologists (May 1984), spokesmen from the
Senate Finance Committee and the Health Care
Financing Administration indicated that it is impos-
sible to establish that the DRG method of reimburse-
ment is an effective method of controlling the cost of
hospital care.
A recent report published in Health Care Notes
(Ernst and Whinney, No. J58514) concludes that DRG
analysis of physician performance can be incomplete
and lead to an improper conclusion. A cardiologist at
a midwest hospital was producing a length of stay and
charges for his patients by DRG which were con-
sistently higher than those of his peers. The hospital
decided to investigate further, using disease staging
techniques which incorporate severity of illness into
the analysis. It then was found that the physician was
treating the cases of greatest severity within each DRG.
It was concluded that this practice pattern actually
was quite efficient.
Disease staging is more effective for audit since, un-
like DRGs, it focuses directly on the severity of a pa-
tient’s illness. It, therefore, provides meaningful infor-
mation and allows comparisons of treatment superior
to that done by DRG.
Ernst and Whinney suggest that hospital adminis-
trators should consider using disease staging to gain
a better understanding of treatment patterns before
attempting to influence physician practices.
MERICAN ASSOCIATION OF MEDICAL
ASSISTANTS-STATE OF NEW JERSEY, INC.
American Association of Medical Assist-
ants-State of New Jersey, Inc., is an outstanding pro-
fessional organization, dedicated to the education and
532
self-improvement of medical assistants. It has mail
tained strong and effective liaison with the Medici
Society of New Jersey and has been a constant abl
and devoted ally of the medical profession.
The House of Delegates of the Medical Society of Ne
Jersey voted to support the American Association <
Medical Assistants-State of New Jersey in the hop}
that this fine organization will continue to grow.
PROSPECTIVE PAYMENT ASSESSMENT
COMMISSION
In a letter to the House and Senate Appropriatio1
Committees, the AMA supported the full budget ap
propriation request for the Prospective Paymer1
Assessment Commission (ProPAC). The AMA state
that “If ProPAC is not afforded adequate funding, u
are concerned that it will be incapable of makin'
reasoned recommendations to the Secretary of the D<
partment of Health and Human Services (HHS), an
that Medicare beneficiaries could suffer if the prosper
tive payment system flounders and hospitals are force
to curtail services or even close their doors.”
MEDICARE AND MEDICAID REIMBURSEMENT OF
PRACTITIONERS WHO LOSE A LICENSE IN ONE
JURISDICTION AND RELOCATE TO ANOTHER
The AMA expressed concern that health care pract
tioners who have been found unfit to practice in on
jurisdiction can relocate and practice in anoth<
jurisdiction where they are licensed. The witneJ
stated that since the AMA Masterfile appears to be th
only source of multistate licensing information o
physicians, the AMA now will notify the medic;
licensure boards when it receives verifiable infoi
mation concerning license revocation, suspension, c
surrender for cause involving physician competency
Also, AMA’s model state discipline legislation will b
updated to include suspension, revocation, or sur
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
nder of a medical license for competency- related
tuse in another state as grounds for disciplinary ac-
)n. The AMA stated that it would support a legislative
oposal to close gaps in the federal government’s
ithority to exclude a sanctioned practitioner from
edicare and Medicaid participation regardless of
censure status in other states.
DNVENTION MANAGER
Ms. Eileen Pfeiffer has been made the manager of
SNJ’s Annual Meeting Convention. We congratulate
s. Pfeiffer on her new position and her fine per-
rmance as manager of the 218th Annual Meeting at
isorts International Hotel and Casino, Atlantic City.
)LICY STATEMENTS: NURSING PROCEDURES
SW JERSEY BOARD OF NURSING
(1) Irrigation of Frontal Sinuses: It is the con-
lered opinion of the Board, that in accordance with
JAC. 45:11-23 et seq., irrigation of frontal sinuses
xild be an inappropriate function of a registered
ofessional nurse.
(2) Intracranial Pressure Monitoring: It is the con-
iered opinion of the Board that according to N.J.SA
»: 11-23: a) injection of fluid into the cranial cavity;
removal of cerebral spinal fluid from an intraven-
cular monitoring catheter; and c) the inclusion of a
ntinuous flush device in the intracranial pressure
le is beyond the scope of professional nursing prac-
:e.
(3) Instillation of Local Anesthetic during Flexible
onchoscopy: It is the considered opinion of the
iard that according to N.J.SA 45:1 1-23, it is beyond
e scope of practice for a licensed practical nurse to
still lidocaine or other local anesthetic through the
onchoscope.
(4) Instillation of Renagrafin 60: It is the con-
lered opinion of the Board that according to N.J.SA
: 11-23, it is beyond the scope of practice for a
ensed practical nurse to instill renagrafin 60 into a
theter during an endoscopic retrograde cholan-
jpancreatography.
(5) Administration of Intravenous Medications
trough a Heparin Lock by Students in Professional
bools of Nursing: It is the considered opinion of the
»ard that students in professional schools of nursing
ay with direct supervision hang intravenous “piggy-
ick” medications which are administered through a
parin lock. The student may flush the heparin lock
th heparinized solution before and after the medi-
tion has been administered according to estab-
hed hospital policy.
MEDICAL HELP FOR TRAVELERS ABROAD
If you are traveling abroad this year, you might wish
to consider signing up with HEALTH CARE ABROAD,
923 Investment Building, 151 1 K Street N.W., Washing-
ton, DC 20005. Telephone: (202) 393-5500. The com-
pany provides a listing of English-speaking doctors in
most major cities abroad (with phone numbers) and,
for $2.50 a day during the trip, would pay your medical
and hospital expenses in any country, as well as for
special travel arrangements should you become unable
to fly home in the normal way.
DRG VALIDATION/CERTIFICATION
The AMA commented on the requirement in the final
regulations on the Medicare prospective payment regu-
lations mandating that the attending physician vali-
date and certify the primary and secondary diagnosis
and procedures performed to allow the review entity
to ascertain the validity of the DRG, and as a condition
for payment to the hospital by Medicare. In objecting
to this requirement the AMA stated that it created
confusion about exactly what is to be certified; terms
were undefined; and that it is both offensive and un-
necessary. The Association went on to say that “Be-
cause of the questionable value and need for certifica-
tion as now required and because of serious concerns
about what the physician is expected to certify, we
need to explore the need and rationale of DRG phy-
sician certification and whether this regulation can be
withdrawn.”
HOSPITAL MANAGEMENT OF INJURIES ARISING
FROM EXPOSURE TO OR INVOLVING IONIZING
RADIATION
The “Guide to the Hospital Management of Injuries
Arising from Exposure to or Involving Ionizing Radi-
ation” was prepared by the AMA’s Department of En-
vironmental and Occupational Health Programs in
response to a resolution adopted by the House of Del-
egates. The report presents a set of guidelines that can
be used by hospital staffs for the initial care of persons
receiving accidental exposures to ionizing radiation or
becoming contaminated with radioisotopes. Single
copies of the report can be purchased for $6.00 plus
$3.50 for shipping and handling. All order inquiries
should be addressed to: Order Department— -OP 35,
American Medical Association, P.O. Box 10946, Chi-
cago, IL 60610.
FINI
Never let yesterday use up today.
3L. 81— NUMBER 7^JULY 1984
533
First-step blood pressure control
with optimal simplicity
Benefits diuretics cannot offer . . . Once daily inde r al la
(propranolol HC1) provides smooth, 24-hour control of blood pressure
plus the cardiovascular benefits of the world’s leading beta blocker.
And INDERAL LA provides a high degree of patient acceptance —
without potassium problems.
Experience no other beta blocker can match .. . Once-daily
INDERAL LA delivers the proven performance and safety profile of
INDERAL tablets — confirmed by millions of patients during 16 years
of clinical use. INDERAL LA should not be used in congestive heart
failure, sinus bradycardia, heart block greater than first degree, or
bronchial asthma.
Start With 80 mg once daily . - - Dosage may be increased to
120 mg or 160 mg once daily as needed to achieve additional control
Please see next page for further details and brief summary of
prescribing information.
80 120 160
mg mg . mg
The ,1/ el INl.V HAL I A c <*/.):
■3 registered trademark o t Avast l addiatan
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION. SEE PACKAGE CIRCULAR )
INDERAL* LA brand ol propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselectlve beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% ot the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect. INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and *gpjiewhat variable. INDERAL has
been shown to cause a small increase in serum potassiffijfconcentration when usee® the
treatment of hypertensive patients , . . ■
In angina pectoris, propranolol generally reduces the^fitgn rec^|i^P#<^#|^B&t
any given level of effort by blocking the catecholamine-1j|8ug^d inceMBfein the hepj&rate,
systolic blood pressure, and the velocity and extent oflHBdial JEtrQction Rroplfinolol i
may increase oxygen requirements by increasing left jg^tieiflar tiber length end diastolic '
pressure and systolic election period 1 he net physiologic effect ol beta-adrei lorgic blockade
is usually advantageous and is mamtested dunrig..6xercise'6y detayed onset ot pain and
increased work capacity Jj|
In dosages greater than required for beta blockade. INDERAL also exerts a quimdine-ljKf?'
or anesthetic-like membrane action which affects the cardiac action potential, fhe signifi-
cance of the membrane action in the treatment of atrj^'hm(j& isSrtceni® M
The mechanism of the antimigraine effect of propranolol has not. been established Beta-
adrenergic receptors have been demonstrated in The piaT vessels of tti@ brain
Beta receptor blockade can be useful in concHftns m.ystiich, because Of pathologie<or
functional changes, sympathetic activity is detrimental to the patient, JiuMthere are also
situations in which sympathetic stimulation is vital i-^examplenn patients wtfn: severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than tirst degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
j II iDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
i agernent of unstable angina pectoris. Since coronary artery disease may be
j unrecognized, it may be prudent to follow the above advice in patients considered at risk
ol having occult atherosclerotic heart disease who are given propranolol for other
indications
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking the j
prior to major surgery is controversial It should be noted, however, that the impaired abil
the heart to respond to reflex adrenergic stimuli may augment the risks of general anestt
and surgical procedures.
INDERAL (propranolol HCI). like other beta blockers, is a competitive inhibitor of tj
receptor agonists and its effects can be reversed by administration of such agents,
dobutamine or isoproterenol. However, such patients may be subject to protracted se
hypotension Difficulty in starting and maintaining the heartbeat has also been reported
bstd blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the1
pearance of certain premonitory signs and symptoms (pulse rate and pressure change]
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be r
difficult to adpst the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthymic
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation ol sympi
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function t
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have I
reported in which, after propranolol, the tachycardia was replaced by a severe bradyc;
requiring a demand pacemaker In one case this resulted after an initial dose of E
propranolol.
PRECAUTIONS. General: Propranolol should be used with caution in patients with imp;
hepatic or renal function INDERAL is not indicated for the treatment of hyperter
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pat
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart dise
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as n
pine should be closely observed if INDERAL is administered The added catecholan
blocking action may produce an excessive reduction of resting sympathetic nervous ac
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthos
hypotension.
Carcinogenesis, Mutagenesis. Impairment of Fertility: Long-term studies in animals
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studr
.bqtbrats Mid mice, employing doses^ugrt.o.150 mg/kg/day, there was no evidence of sigmt.
drug-inditced toxicity rheae'4jfce-fio drug-related tumorigemc effects al any ot the do:
flevelf? Reproductive studies animals did not show any impairment ol fertility that
, attnbiitable lo the drug.
fia /SKglBncy JHHncy Category C JJNDERAL has been shown to be embryotox
' animal studies atidoses about 10 tirrsesyre^ter than the maximum recommended human c
There are no adequate and welt-controlled studies in pregnant women INDERAL sr.
be used during pregnancy only if the potential benelit justities the potential risk to the fi
Nursing Motjjms INDERAL is excreted in human milk Caution should be exercised v
ajNDERAL is administered to a nutsing wopian
“ C flMiic Use: SafdTy and effeclivefRs in children have not been established
ADVERSE REACTtlONS. MosLad.i^se effects have been mild and transient and
rjrely: required the withdrawal bf/therapy
Gawjova$cular: bradycardia; congestive heart failure, intensification of AV block; h
' tensioMfea^feiesia ot bands thrombocytopenic pturpura arterial insufficiency, usually c
™*Raynaumlype“*' --i.----' »•*“
Central Nervous Sys/err£;&|jj)fheadedness, mental depression manifested by msor
lassitude, weakness, fatigudn^ersible mental depression progressing to catatonia, v
disturbances; hallucinations, an acute reversible syndrome characterized by disorientate
time and place, short-term memory loss, emotional lability, slightly clouded sensorium,
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, dian
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with ac
and sore throat, laryngospasm and respiratory distress.
Respiratory, bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytop
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has I:
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male ir
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reao
involving the skin, serous membranes and conjunctivae reported for a beta blocker (praci
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride
sustained-release capsule for administration once daily If patients are switched from INDE
tablets to INDERAL LA capsules, care should be taken to assure that the desired therap'1
effect is maintained INDERAL LA should not be considered a simple mg for mg substitul
INDERAL INDERAL LA has different kinetics and produces lower blood levels. Retitration
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inte
HYPERTENSION — Dosage must be individualized The usual initial dosage is 8C
INDERAL LA once daily, whether used alone or added to a diuretic The dosage ma
increased to 120 mg once daily or higher until adequate blood-pressure control is achie.
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage o
mg may be required. The time needed for full hypertensive response to a given dosai
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAj
once daily, dosage should be gradually increased at three to seven day intervals until optu
response is obtained Although individual patients may respond at any dosage level
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few w|
(see WARNINGS).
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERA
once daily. The usual effective dose range is 160-240 mg once daily The dosage ma i
increased gradually to achieve optimum migraine prophylaxis It a satisfactory response i
obtained within four to six weeks after reaching the maximum dose, INDERAL LA the
should be discontinued. It may be advisable to withdraw the drug gradually over a peril
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group an
limited to permit adequate directions for use.
•The appearance of INDERAL LA capsules is a registered trademark of Ayerst LaboratO
AQ5G t
Nomalllergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
536
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ROFESSIONAL LIABILITY
OMMENTARY*
Courses and
Contracts
Clinicolegal Correspondence Course;
Lawyers, Beware; Climate Improving for
Malpractice Tort Reform
Over the last several years, pro-
fessional liability lawsuits have
become a part of the practice of
isdicine. While in theory, the central issue is the
aality of medical care rendered, often factors which
I in the environment surrounding the question of
batmen t decide whether the plaintiff or the defen-
(nt prevails. Such things as the manner in which
batmen t is documented in the record or the way in
jinich a defendant handles an attorney’s questions are
; important as the facts of the case. Additionally, in
irtain cases a prior knowledge of what the law re-
< tires may have enabled the physician to avoid becom-
ig involved in the suit in the first place.
Recognizing a need to provide information on the
1 v as it applies to the practice of medicine, the leader-
tip of the Medical Inter-Insurance Exchange of New
i rsey (MIIENJ) commissioned Dr. James E. George, a
pysician and an attorney, to develop a correspon-
< nee course which would fill this need. This work was
rmpleted in late 1983, and since the course’s
itroduction in January 1984, 2,500 physi-
<ms have enrolled.
The course was written to inform the physician,
i ther than try to make him into a student of the legal
1 iguage. It is divided into 24 chapters, each covering
isingle major subject. It begins by reviewing basic
1 gal principles, and progresses to such subjects as
' thdrawal of life-support systems, emergency psy-
wiatric commitment, and countersuits. After pre-
nting information on each subject, actual case cha-
ins are presented to demonstrate how the law under
discussion was applied. Each chapter ends with sev-
eral test questions. After answering all of the ques-
tions, the answer sheet is returned to MIIENJ. The
sheet is graded and returned to the physician with a
pamphlet which gives an explanation of the answer to
each question.
Upon successful completion of the course and the
test, the physician is eligible for an award of 20 hours
of Categoiy I CME Credit (or Category 2-B in the CME
program of the American Osteopathic Association, if
appropriate). Also earned is a two-point reduction in
any point total incurred under the High-Risk Evalu-
ation Program. The course is free to any MIIENJ in-
sured, and is available to physicians insured by any
other carrier at a fee of $75. Anyone interested can
obtain a copy by sending name, address, and specialty
to the Risk Prevention Department, Medical Inter-ln-
surance Exchange of New Jersey, P.O. Box 6470, Law-
renceville, NJ 08648.
LAWYERS, BEWARE!
New Jersey is cracking down on lawyers who bilk
clients or engage in unethical conduct. Last year 1,967
complaints were filed against lawyers, while in 1982
exactly 2,038 complaints were lodged, the State
Division of Consumer Affairs said.
Last year there were 319 ethics complaints lodged
against New Jersey doctors, 233 against 14,500 den-
tists, and 95 against 90,7 1 7 nurses, division Director,
James Barry said. (Trentonian, March 20, 1984)
CLIMATE IMPROVING FOR MALPRACTICE
TORT REFORM
The public climate for tort reform may be improving.
A yearly public opinion survey, conducted by an inde-
pendent firm for the American Medical Association
last year, shows growing support for limits on the
amount of money that could be awarded in a malprac-
tice suit. Nearly two-thirds (62 percent) said they
favored such a cap.
In a 1982 survey, public respondents flatly rejected
giving up the right to sue for malpractice, but increas-
ing concern about rising health care costs apparently
has made the ceiling on awards more acceptable.
The public also may be developing an increasing
perception that some malpractice suits are without
merit. When asked if people who sue physicians
usually are justified in bringing suit the number who
said yes dropped from 47 percent in 1982 to 41 percent
in 1983. The number who said people who sued were
“just looking for an easy way to make money" rose from
43 percent in 1982 to 47 percent in 1983.
Slightly less than half of the respondents said juries
awarded too much money to successful plaintiffs in
malpractice suits while about one-third said the
amounts awarded were about right. ( Loss Mlnlmlzer,
February 1984)
’This item from the Department of Professional Liability Con-
trol, MSNJ. was prepared by James E. George, M.D.. J.D., and
A Ronald Rouse who are, respectively. Director of the Depart-
ment and Director of Special Projects.
OL. 81 -NUMBER 7-UULY 1984
537
FIFTH ANNUAL MEDICOLEGAL SEMINAR
Wednesday, September 12, 1984
8:30 a.m.- 4:00 p.m.
Medical Society of New Jersey Executive Offices
Two Princess Road
Lawrenceville, NJ 08648
presented by
Medical Society of New Jersey
Department of Professional
Liability Control
Medical Inter-Insurance
Exchange of New Jersey
Department of Risk Management
Morning Session
8:30 Registration and Coffee
Greetings
Frank Y. Watson, M.D., President,
MSNJ and James S. Todd, M.D.,
Chairman of the Board, MIIENJ
9:00
9:20
9:45
Opening Remarks
James E. George, M.D., J.D.,
Director, Department of Professional
Liability Control
“The Snitch Bills; Their Impact
on Medical Malpractice”
Vincent A. Maressa,
Executive Director, MSNJ
1:00
10:15
“Reporting of Medical Malpractice To
State Board of Medical Examiners”
Joseph A. Riggs, M.D., Member of State
Board of Medical Examiners
10:45
11:15
“The New Case Management and
Procedures of Malpractice Litigation”
Honorable Peter Ciolino, Assignment Judge
Superior Court, Passaic County
Questions and Answers
Afternoon Session
12:00 Lunch
12:45 “Medical Malpractice; The
View from the Chair”
James S. Todd, M.D.
Chairman, Board of MIIENJ
“The Professional Liability
World Today; The State of
the Industry”
Peter Sweetland, President,
MIIENJ
“The Claim Climate in New
Jersey; A History and a
Look at the Future”
Joseph DeRoma, Vice-President,
Claims, MIIENJ
“An Ounce of Prevention;
Causes of Suits and Programs
Developed To Avoid Them”
Adam P. Wilczek, Director,
Department of Risk Management,
MIIENJ
Questions and Answers
1:45
2:30
3:15
APPROVED FOR 5% CME CATEGORY I CREDITS
REGISTRATION
PLEASE RESPOND NO LATER THAN AUGUST 31, 1984
NO REFUNDS AFTER SEPTEMBER 10, 1984
MSNJ MEMBER OR MIIENJ INSURED
NON MSNJ MEMBER OR
NOT INSURED WITH MIIENJ
$10.00
25.00
DETACH AND MAIL TO MSNJ, TWO PRINCESS ROAD, LAWRENCEVILLE, NJ 08648
Enclosed is my check for payable to MSNJ
NAME (PLEASE PRINT)
ADDRESS
PHONE #.
A CONFIRMATION WILL BE SENT TO YOU ALONG WITH DIRECTIONS TO MSNJ.
538
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1:
;
' TAX SHELTERS '
Just one of the personal
financial services
available to you from the
physician's bank.
• tax planning
• lines of credit
• equipment financing
• retirement planning
• money management
• cash flow • investments
• estate planning
Call or Write
Joseph J. Verbaro, Jr.
Senior Vice President
(201) 228-9770
FiVTllST
J FINANCIAL AND TRUST SERVICES ~J
DIVISION OF SECURITY NATIONAL BANK & TRUST COMPANY
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OL. 81— NUMBER 7— JULY 1984
539
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Editorial
iPECIAL
The Academy of
Medicine of
New Jersey Awards
The Academy of Medicine of New Jersey
held their Annual Awards Dinner on
May 23, 1984, and honored AMNJ
President Rigolosi and Dr. Alessi, the
Edward J. Ill Award recipient.
The Academy of Medicine attend-
ees of the Annual Awards Din-
ner (May 23, 1984) received an
riginal limited edition print by Richard Kemble of
/ashington Crossing, Pennsylvania. The print, repro-
uced on our cover, is an image which is a semi-ab-
tract impression entitled, “Mercer Oak,” the Oak tree
a Princeton Battlefield. Kemble’s travels and studies
l Japan inspired his interpretation by way of
apanese calligraphy.
At the Awards Dinner, Robert S. Rigolosi, M.D., was
laugurated as the new president of The Academy of
ledicine of New Jersey.
Medicine or boxing . . . which would it be? That de-
sion had to be made by Bob Rigolosi in his senior
ear in college when he advanced to the finals of the
lympic trials and had the opportunity to travel to
lelboume, Australia, with the United States Olympic
earn. For a tough kid of immigrant parents, bom and
iised in Garfield, boxing would appear to be the likely
hoice, but, as we know, our new President chose medi-
ine.
Foregoing a boxing career, Dr. Rigolosi graduated
om Syracuse University and went on to the Univer-
ity of Rome Medical School. After that, it was an in-
imship at Hackensack Hospital and a residency at
ronx VA Hospital. Awarded a fellowship by the Na-
ional Institutes of Health, Dr. Rigolosi then studied
mal-metabolic diseases for two years at Georgetown
diversity Hospital.
Following his fellowship. Dr. Rigolosi got together
nth Holy Name Hospital, Teaneck to start the Re-
ional Hemodialysis Center. From an inauspicious be-
inning in the hospital basement in 1969, the Center
nder Dr. Rigolosi grew to one of the largest
Robert S. Rigolosi, M.D.
hemodialysis facilities in New Jersey and to one of the
largest community hospital units in the countiy.
But his dedication to his profession extended far
beyond his work at Holy Name Hospital. He got in-
volved, very involved.
In 1969. Governor Cahill appointed Dr. Rigolosi to
the Chronic Renal Disease Advisoiy Committee of the
Department of Health. During the next eight years, he
OL. 81 -NUMBER 7-JULY 1984
541
was elected its chairman on three occasions.
In 1977, he was elected president of the Bergen
County Medical Society.
In 1979, Governor Byrne appointed our President as
a trustee of the Statewide Health Coordinating Council
(SHCC), a position he still holds.
In 1980, Dr. Rigolosi was elected chairman of the
Bergen— Passaic Health Systems Agency (HSA), the
first physician ever elected to the top post of any HSA
in the state.
Dr. Rigolosi has been a member of The Academy of
Medicine since 1970, having actively served on several
committees, including medical education and mem-
bership. He has been a Trustee since 1977.
The contributions which Dr. Rigolosi has made to
the medical community, and beyond, have been rec-
ognized by such charitable organizations as the Na-
tional Council of Christians and Jews, which pre-
sented him with their Brotherhood Award in 1978 . . .
by the Bergen County Boys Town of Italy, which gave
him the Citizen of the Year Award in 1981 ... by the
National Kidney Foundation of New York/New Jersey,
which honored Dr. Rigolosi with the National Medical
Award in 1983.
Dr. Rigolosi lives in Paramus with “my raison d’etre,”
Alfred A. Aiessi, M.D.
Marguerite, and their four children— Robert, Rebecc;!
Luke, and Laura
Alfred A. Aiessi, M.D., a vascular surgeon from 0 !
adell, is the 1984 recipient of The Academy of Medicirr
of New Jersey’s Edward J. Ill Award.
Bom in New York City, he grew up in Rutherfor
where he was graduated from high school. He receive
his premedical education at Colgate University and hi
medical degree from the New York University Colleg:
of Medicine. In addition, he was granted an M.S. fror
Fairleigh Dickinson University.
Dr. Aiessi served internships and surgical res
deneies at the City Hospital, New York, between 193
and 1942. During the period 1942 to 1945, he was i
the US Army at the 14th Evacuation Hospital in Indi
where he attained the rank of major and was decorate
with the Bronze Star for Meritorious Service.
Life has been a mixture of surgical practice an
service to medicine for Dr. Aiessi. In addition to bein
the past director of surgery and past chief of vascula-
surgery at the Hackensack Medical Center, he ha
served as chairman of numerous committees of tha !
hospital and as a member of its Committee of Director
and its Board of Governors. His service to the Berge
County Medical Society and the Medical Society of Nef
Jersey has been tireless, having served as their pres
dents in 1974 to 1975 and 1979 to 1980, respectively
Dr. Aiessi is recognized as the first vascular surgeoi
to be established in New Jersey (1946) and has helpe
train over 1,500 surgical residents at the Hackensac
Medical Center. He has been a president of the Amer
can College of Surgeons, New Jersey Chapter, a men
ber of the New Jersey Regional Medical Program, an
numerous national vascular societies. He is
Diplomate of the American Board of Surgery and
Fellow of the American College of Surgeons as well a
the International College of Surgeons. He serves a
director of medical education for The Academy of Med>
cine as well as being a member of its Board of Trustee;
He has authored a number of scientific papers oi
various surgical topics and currently serves as Clinic;
Professor of Surgery at the UMDNJ-New Jersey Medic;
School. He also serves as Adjunct Professor of Humai
Physiology at the Fairleigh Dickinson University.
In the last year and one-half he has traveled ove
65,000 miles on behalf of the American Medical As
sociation addressing the impacts, concerns, and im
plications of the DRG program.
Dr. Aiessi is married to the former Isabel Molinar'
and they are the parents of four children— Joan, Alfrec
Louise and Thomas.
!
i
j
542
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
II
II
Pitorial
ASNJ: 218th
Annual Meeting
S
f
he MSNJ Annual Meeting, May 3 to 6,
984, had its exciting and significant
laments.
America’s first Medical Society
had its 218th Annual Meeting
at Resorts International in At-
stic City. A new president was elected and the office
.'hairman of the Board of Trustees was eliminated.
Hceforth the president will act as the chief executive
leer of the Society.
rank Y. Watson was inaugurated as the 192nd
1 sident of the Medical Society of New Jersey. In his
roduction to the House of Delegates, Dr. L. Arne
' lbred made the following remarks:
It is an honor and a pleasure for me to introduce
:you my long-time friend, Frank Watson, as the
Ind President of the Medical Society of New Jersey,
When we pick a president for our organization, we
jk for leadership qualities. In my opinion, the four
: st important qualities are experience, intelligence,
mmitment, and political awareness:
Frank Watson has experience as a leader. He has
jin director of the laboratories at The Mountainside
ispital for the past 1 1 years. He has been president
1 The Mountainside Hospital medical staff for 2 years
a has been president of Essex County Medical So-
lly. He has been on the Board of Trustees of the
'dical Society of New Jersey and an officer of the
i dical Society of New Jersey for the past several years.
After many years of association, I can testily that
ink Watson knows all the answers. After all, he is
l chief pathologist at my hospital and I am a sur-
S »n; he is the one who always tells me the answer.
Frank Watson also had the “smarts” to marry Dr.
Carolyn Watson. We are indeed fortunate to have an
outstanding husband/wife team with an interest in
organized medicine; both are alternate delegates to the
AMA House of Delegates.
“Anyone who knows Frank Watson knows his
serious approach to any job or any problem. He doesn’t
shirk any responsibility. His commitment to the Medi-
cal Society of New Jersey can be exemplified by his
many trips from his home in Glen Ridge to Trenton
and Lawrenceville, in good weather and bad, over the
past ten years to attend committee meetings. Board of
Trustee meetings, and legislative hearings.
“In these troubled times for medicine, with more and
more legislative and regulatory interference, we are
fortunate to have Frank Watson as a president. He has
had a special interest in legislative matters. He has
been chairman of JEMPAC and represented us at legis-
lative hearings.
Frank Watson is the most appropriate person to be
President of the Medical Society of New Jersey at this
time.”
The Board of Trustees issued the following report
concerning specialty society representation in the
Medical Society of New Jersey’s House of Delegates:
Pursuant to the Bylaws, we considered the appli-
cations of 26 specialty societies for seating in this
House. Thirteen of the societies met the standards
established in our Bylaws. We, therefore recommend
that the following specialty societies be granted Del-
egate status:*
New Jersey Dermatological Society
New Jersey Gastroenterological Society
New Jersey Society of Internal Medicine
Neurological Association of New Jersey
New Jersey Neurosurgical Society
Oncology Society of New Jersey
New Jersey Academy of Ophthalmology and
Otolaryngology
New Jersey Orthopaedic Society
New Jersey Society of Plastic and Reconstructive
Surgeons
Radiological Society of New Jersey
New Jersey Chapter, American College of Surgeons
New Jersey Society of Thoracic Surgeons
Urologic Society of New Jersey
The following specialty societies met Bylaw criteria
with one exception. They did not establish that 80
percent of their membership are members of the Medi-
cal Society of New Jersey. Consequently, they are not
recommended for approval. They have been advised to
reapply whenever the ratio of their Medical Society of
New Jersey membership improves:
New Jersey Allergy Society
New Jersey State Society of Anesthesiologists
American College of Chest Physicians, New Jersey
Chapter
New Jersey Society of Colon and Rectal Surgeons
American College of Emergency Physicians, New
Jersey Chapter
New Jersey Academy of Family Physicians
Nephrology Society of New Jersey
Obstetrical and Gynecological Society of New Jersey
New Jersey Society of Pathologists
L. 81— NUMBER 7— JULY 1984
543
American Academy of Pediatrics, New Jersey
Chapter
New Jersey Society of Physical Medicine and
Rehabilitation
American College of Physicians of New Jersey
New Jersey Psychiatric Association
*Under the Bylaws, the Medical Society of New Jersey
Student Association is considered a specialty society,
and its members are recognized as members of the
Medical Society of New Jersey.
It is sad that such important groups as the
anesthesiologists, the internists in the American Col-
lege of Physicians, the family practitioners, the ob-
stetricians, and the others are not “in the fold.” The
80 percent rule may seem stringent, but I can think
of no acceptable excuse for failure to belong to the
blanket medical organizations— the American Medical
Association and the Medical Society of New Jer-
sey—which are the physicians’ only hope to preserve
any fraction of independence. As important as the
specialty societies are, they cannot have the political
clout nationally or in New Jersey that makes a dif-
ference.
The Medical Society of New Jersey has established
a Hospital Medical Staff Section for the first time, in
accordance with an AMA House of Delegates resolution
(1983). The anticipated benefits of the new section
both to MSNJ and to each hospital medical staff are
as follows:
1. Provide a system to solve problems and to avoid
polarization of medical staffs and other groups
of physicians.
2. Provide a vehicle to identify the implications of
future trends on the role of physicians individu-
ally and as members of medical staffs.
3. Acquaint medical staff leadership with policy
structure in organized medicine.
4. Provide appropriate support to local and state
medical staff representatives.
5. Develop and maintain information on issues of
common concern to medical staffs and distribute
data on successful approaches.
6. Provide an easy contact point for medical staff
leaders with AMA and MSNJ resources.
The Committee on Annual Meeting sent shock waves
through Reference Committee “B” and the House of
Delegates when it announced that no suitable site
could be found in New Jersey for the 219th Annual
Meeting, May 2 to 5, 1985. The Board and the Commit-
tee worked diligently, but Resorts International was
interested more in gamblers than in New Jersey phy-
sicians. Since no suitable alternative location was
available, the decision to use the Americana Host Farm
Resort and Conference Center in Lancaster, Penn-
sylvania, was made.
“Mandatory assignment” were buzz words this year.
The House adopted two key resolutions:
• That the Medical Society of New Jersey request
the American Medical Association to oppose vig-
orously any attempt by Congress to direct in any
fashion mandatory assignment under Medicare.
• That the Medical Society of New Jersey resear -
the constitutionality of the concept of mandate
assignment being proposed by Congress or a!J
other proposal to force physicians to acctt
prestipulated fees.
Dr. Donald J. Holtzman, president of Union Coui /
Medical Society read a statement on the subject to 1 «
House: a portion states:
‘Thursday, April 12, 1984, was a crucial day -
American medicine. On that day, the American Medi 1
Association fought back an attempt to impose involi ^
tary servitude by the government upon every pract i
ing physician in the United States.
“If mandatory assignment had passed, you wovl
have been required to sign an agreement with ycr
hospital to accept Medicare assignment for all inp
tient care or lose all staff privileges. In effect, you wot .
not have been able to work at your profession.
“If it had not heen for organized medicine, th
would be your plight today. If it had not been for D
voluntary freeze in fees, a mandatory freeze would nt
be in effect.
‘This incredible effort to prevent your financi ;
enslavement must not go unnoticed by you. Any doct
who does not belong to the AMA should not let th
day pass without writing out a check for his du<
What a small price to pay for their service to you.
The House also adopted two relevant resolutioi
dealing with compensation for physicians’ services
• That the Medical Society of New Jersey develop
contingency plan to enable the Society, or an c
ganization it sponsors, to act as a collectiv
bargaining agent for its members, and that tl
AMA be asked to develop similar plans.
• That the House of Delegates of MSNJ demand th
Blue Shield and all major medical insurance ca
riers permit access both by participating and no
participating physicians to any major medical i;
surance coverage sold as part of a benefits pac
age and that legal action be taken as deemed a];
propriate by the Board of Trustees if this demar,
is not respected.
The House adopted a resolution (and a propose
special assessment for funding) for an important pul
lie education program:
• That the Medical Society of New Jersey condue
a “patient education” program, designed to ii
form the general public regarding the unde
publicized factors involved in health care cosl
and the threat posed to the quality and avai
ability of said care.
The 218th Annual Meeting had its exciting and sit
nificant moments. Those physicians who fail to corr
prehend the importance of membership in the Amer
can Medical Association and the Medical Society c
New Jersey are making a mistake.
With a touch of irony, the Medical Society of Ne'
Jersey’s democratic assemblage will meet for the 219t
time since 1766 in, of all places, Pennsylvania We hop
to see you there. AI
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’ij
544
[ospital Governing
ioards*
Salaried Physicians
(Pathologists) and Due
Process Hearings
Vincent A. Maressa, j.d.
The U.S. Court of Appeals held that a
hospital may terminate an employment
contract with its director of pathology
without due process procedures.
i
A Federal District Court decision
in Minnesota regarding salaried
physicians has been affirmed by
ie United States Court of Appeals for the Eighth
Circuit This case, Engelstad v Virginia Municipal Hos-
ital, No. 83-141 1 (8 Cir., September 29, 1983), is sig-
ificant to physicians and hospital governing boards.
The Court held that a hospital may terminate an
mployment contract with its director of pathology
Jjthout affording “due process” procedures, including
hearing before the hospital’s executive committee,
/hich is called for by the hospital’s bylaws.
The pathologist was functioning under a long-stand-
ig oral agreement. He was terminated for failure to
roperly supervise personnel and for ineffective man-
gement. He also was in frequent conflict with the
dministration and the medical staff. Although ter-
linating his employee status, the hospital did not
isturb his staff privileges.
The doctor filed the lawsuit as a federal civil rights
ction. The Court rejected his argument on that issue
hd said the case must be decided as a matter of
ontract law. Employment contracts are terminable at
dll unless there is a specific contractual under-
tanding to the contrary.
The pathologist then attempted to argue that the
termination of his employment resulted in a reduction
of staff privileges without a due process hearing under
the hospital’s bylaws. The Court did not accept this
argument. It viewed staff privileges as guaranteed
authority but not the “wherewithal” to practice his
profession. It stated the hospital had the right to ter-
minate the “wherewithal” at its options without due
process hearings which are afforded to doctors whose
privileges are challenged because of alleged in-
competence or unethical behavior.
While there are no reported New Jersey cases dealing
with this particular situation, it is reasonable to as-
sume that our courts would reach the same con-
clusion.
Salaried physicians and hospitals would be well ad-
vised to utilize the protection afforded both parties by
properly executed written contracts and to pay particu-
lar attention to a clearly written termination clause.
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A Maressa, J.D.,
Executive Director, MSNJ; and James E. George. M.D., J.D.,
Director of Professional Liability, MSNJ.
'OL. 81— NUMBER 7^JULY 1984
545
ONLY DALMANE (flurazepam HCI/Po
~ I PROVIDES all these bene
FOB RESTFUL SLI
• Rapid sleep onset
' e total time^asleeji
> • Unuiminished~efficacy for at lea
28 consecutive nights'
• Patients usually awake rested ar
* refreshed
• Avoids causing early awakenings c
rebound insomnia after discontinuation2 5 10
by Roche Products Inc. All rights reserved
15-MG/30-MG CAPSULES
Caution patients about driving, operating hazardous machinery or drinking
alcohol during therapy. Limit dose to 15 mg in elderly or debilitated patients.
Contraindicated during pregnancy.
See next paj
■oduct information
DALMANE
flurozepam HCI/Poche
References: 1. Kales J et al Clin Pharmacol Ther
72:691-697, Jul-Aug 1971 2. Kales A et al Clin Phar-
macol Ther 18 356-363, Sep 1975 3. Kales A et al
Clin Pharmacol Ther 79:576-583, May 1976 4. Kales A
et al: Clin Pharmacol Ther 32:781 -788, Dec 1982
5. Frost JD Jr, DeLucchi MR: J Am Geriatr Soc
27 541-546, Dec 1979 6. Kales A, Kales JD J Clin
Pharmacol 3:140-150, Apr 1983 7. Greenblatt DJ,
Allen MD, Shader Rl Clin Pharmacol Ther 21 :355-361 ,
Mar 1977 8. Zimmerman AM Curr Ther Res
73:18-22, Jan 1971 9. Amrein R et al: Drugs Exp Clin
Res 9(1 ) 85-99, 1983 10. Monti JM Methods Find Exp
Clin Pharmacol 3 303-326, May 1981 11. Greenblatt DJ
etal: Sleep 5(Suppl 1):S18-S27, 1982 12. Kales A
et al Pharmacology 26 121-137, 1983
DALMANE* <E
flurazepam HCI/Roche
Before prescribing, please consult complete
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restful sleep Objective sleep laboratory data have
shown effectiveness for at least 28 consecutive nights
of administration Since insomnia is often transient
and intermittent, prolonged administration is generally
not necessary or recommended Repeated therapy
should only be undertaken with appropriate patient
evaluation.
Contraindications: Known hypersensitivity to fluraze-
pam HCI; pregnancy. Benzodiazepines may cause
fetal damage when administered during pregnancy
Several studies suggest an increased risk of congeni-
tal malformations associated with benzodiazepine use
during the first trimester Warn patients of the potential
risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam Instruct
patient to discontinue drug prior to becoming preg-
nant. Consider the possibility of pregnancy prior to
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Warnings: Caution patients about possible combined
effects with alcohol and other CNS depressants. An
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day following use for nighttime sedation This potential
may exist for several days following discontinuation
Caution against hazardous occupations requiring
complete mental alertness (e g , operating machinery,
driving) Potential impairment of performance of such
activities may occur the day following ingestion. Not
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age Though physical and psychological dependence
have not been reported on recommended doses,
abrupt discontinuation should be avoided with gradual
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Precautions: In elderly and debilitated patients, it is
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J
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
548
)ut of-Hospital Births
i Survey of Parents
VlARGARET GREGORY, M.D., ROBERTA B. McDONOUGH, R.N., LINDA MACIOROWSKI, R.N.,
Eva Miller, m.s„ trenton*
Questionnaires were mailed to 900 families, of whom 300 had
out-of-hospital births and 600 had inhospital births; 695
questionnaires were deliverable. Of the families reached , 469
[67.4 percent) responded. Contact and response rates did not
justify sweeping conclusions but there were indications of
differences in services given to separate groups.
Out-of-hospital births have in-
creased in New Jersey over the
last five years from 250 in 1976
546 in 1980. The percentage of births that occurred
ut-of-hospital increased from 0.27 percent in 1976 to
58 percent in 1980.
Little was known about the health needs of these
others and children. For example, there was no way
know if the babies received vitamin K or ophthalmia
ophylaxis, if blood specimens were taken for PKU
id for hypothyroidism screening, or if the mother
quired treatment for complications of labor and de-
ery, or received timely family planning services. The
ibsequent course of infant and child was unknown:
ere was a suspicion that these babies might remain
it of the health care system, not receiving immuniza-
)ns or other elements of good child health super-
sion.
Outcome of out-of-hospital births and particularly of
>me births has been examined by Mehl et al.,1 Sim-
ons,2 and Burnett et al.3 However, there are no re-
>rts which answer these specific public health ques-
ts about services given to mothers and children. For
is reason, a questionnaire was sent to families ex-
Tiencing births in and out of the hospital in 1979.
ie self-administered questionnaire included items
>out several services that mothers and/or children
ould be expected to receive as part of good health
iipervision. It also asked for some other nonmedical
JL. 81— NUMBER 7^JULY 1984
information and for one subjective judgment.
The main intent of the questionnaire was to elicit
information that would enable us to answer what we
considered to be an important public health question:
Did those mothers and babies who had out-of-hospital
deliveries have special public health needs which
mothers and babies having inhospital deliveries did
not have, or had to a markedly lesser degree?
METHOD
A systematic random sample of 300 New Jersey
mothers was chosen from among the 65 1 out-of-hospi-
tal births reported to New Jersey Vital Statistics in
1979. Two controls (mothers whose babies were bom
inhospital and mothers whose babies were bom out-
of-hospital) were selected for each case. Controls were
selected from the pool of inhospital births after or-
ganizing the file by maternal residence, marital status,
race, parity, maternal age (± three years), and date of
birth. Residence was considered to be an important
factor, both as a socioeconomic indicator and as an
indicator of proximity to and availability of medical
services. (For small municipalities it sometimes was
impossible to find controls in the same municipality
*From the Maternal and Child Health Program, New Jersey
State Department of Health. Correspondence may be ad-
dressed to Dr. Gregoiy, New Jersey State Department of
Health, John Fitch Plaza, CN 360, Trenton, NJ 08625.
549
l
TABLE 1
Service to Babies
Service or Procedure
Inhospital Births
Home Births
Birthing Center
Other Births
Performed
Planned
Unplanned
Planned
Unplanned Births Planned*
Unplanned*
Hemorrhagic disease of the
newborn prophylaxis
20
(6.15%)
0
9
(16.98%)
1
(2.70%)
13
(38.24%)
0
Screening test (PKU and
271
2(66.67)
41
29
33
10
hypothyroidism)
(93.38)
(NA)
(77.36)
(78.38)
(97.06)
(90.91)
Ophthalmia neonatorum
226
2(66.67)
25
23
27
6
prophylaxis
(69.54)
(NA)
(47.17)
(62.16)
(79.41)
(54.55)
Immunizations started by
303
2(66.67)
36
30
28
10
three months
(93.23)
(NA)
(67.92)
(81.08)
(82.35)
(90.91)
Infant complications reported
68
1(33.33)
2
9
5
4
(20.92)
(NA)
(3.77)
(24.32)
(14.71)
(36.36)
Total
325
3
(Plus NA)
53
37
34
11
NA= No answer; * =There were no unplanned birthing center births and no planned other births.
TABLE 2
Services to Mothers and Children
Inhospital Births
Home Births
Birthing Center
Other Births
Services
Planned
Unplanned
Planned
Unplanned Births Planned*
Unplanned*
Family planning advice
146
2(66.67%)
25
16
28
3
(44.92%)
(NA)
(47.17%)
(43.24%)
(82.35%)
(27.27%)
Examination of baby by nurse
264
1(33.33)
49
35
34
7
or doctor within one week
(81.23)
(NA)
(92.45)
(94.59)
(100)
(63.64)
Visit by nurse or doctor within
112
2(66.67)
43
22
9
1
two weeks
(34.46)
(NA)
(81.13)
(59.46)
(26.47)
(9.09)
Examination of mother within
305
3(100)
45
33
32
9
six weeks
(93.85)
(NA)
(84.91)
(89.19)
(94.12)
(81.82)
Total
325
3
53
37
34
11
NA=No answer; *=There were no unplanned birthing center births and no planned other births.
so another municipality in the same county of similar
population and per capita income was substituted.)
While maternal education may be a relevant factor it
was not used in selection of controls because it is not
reliably reported on birth certificates.4 The question-
naire is reproduced in the Figure. A Spanish version
of the questionnaire and letter was prepared and used
where indicated by information on the birth
certificates.
The questionnaire was pretested for com-
prehensibility and ease of answering by four New Jer-
sey State Department of Health employees. These em-
ployees recently had babies and were all nonhealth
professionals. They all judged the questionnaire to be
readily understandable and easy to answer.
The questionnaire was mailed along with a cover
letter and a stamped, self-addressed return envelope.
The cover letter included information on the purpose
of the study, use of data and a phone number to call
il further questions or explanations could be provided.
Parents were invited to phone about concerns. Items
covered in the questionnaire are listed in Tables 1 to
3.
A followup mailing was sent two months after th
first to those families who had not responded. Thi
letter reminded the families of the first one, reassure
them about the confidentiality of the survey, and iri
vited them to call the Maternal and Child Health Pro
gram to speak to nurses about any concerns the
might have.
While questionnaires were numerically coded so tha
responses could be linked with information from th
baby’s birth certificate, confidentiality was maintained
by careful handling of numeric linkage lists, separ
ation of these lists from the data, and security code:
in the computer library. Also, no individually iden
tifiable data were maintained in written material re
lated to the survey. A cut-off date of six weeks frorr
mailing was established.
Responses were compared for the two samples as a
whole, using standard statistical techniques such a ;j
means, chi-square, and Fisher's exact test for dif
ferences between the groups for categorical variables
Matched analysis techniques could not be used be
cause of the low response rates and small number o
matched pairs in the final data set.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
550
TABLE 3
Social and Economic Questions
Inhospital Births
Home Births
Birthing Center
Other Births
Question
1. Why did you plan to
have your baby bom
in the setting you chose?
Planned
Unplanned
Planned
Unplanned Births Planned*
Unplanned*
a Cost was a factor.
21
1
10
2
15
1
b. Level of
(6.46%)
(33.33%)
(18.87%)
(5.41%)
(44.12%)
(9.09%)
independence
12
1
41
1
27
0
was factor.
(3.69)
(33.33)
(77.36)
(2.70)
(79.41)
c. Desired home like
setting.
6
(1.85)
2
(66.67)
47
(88.68)
0
31
(91.18)
0
d. Safety was factor.
273
1
30
28
16
8
(84.00)
(33.33)
(56.60)
(75.68)
(47.06)
(72.73)
e. Other.
53
1
14
2
10
3
(16.31)
(33.33)
(26.42)
(5.41)
(29.41)
(27.27)
2. Were you pleased with
279
1
52
33
34
7
your birthing experience?
Yes answers
(85.54)
(33.33)
(98.1 1)
(89.19)
(100.00)
(63.64)
3. Would you plan to give
birth in the same place
again? Yes answers
256
(78.77)
0
51
(96.23)
8
(21.62)
31
(91.18)
0
Total
325
3
(NA)
53
37
34
11
NA= No answer; * =There were no unplanned birthing center births and no planned other births.
SULTS AND DISCUSSION
)verall, 695 surveys were deliverable, (77.2 percent),
the families reached, 469 (67.4 percent) responded,
contacted 178 (59.4 percent) mothers having out-
lospital births and 517 (86.2 percent) mothers
/ing inhospital births. Of these 695 mothers con-
ted, 137 (77 percent) of the 178 with out-of-hospital
i 332 (64.2 percent) of the 517 with inhospital
ths responded to the survey questions.
'he overall response rate based on number of letters
it out was 52.1 percent.
'he number contacted and the response rates were
(appointing and the difference in the contact and
ponse rates in the in- and out-of-hospital birth
iups has diminished the confidence with which the
ormation obtained can be used,
lowever, given these impediments, it still was con-
ered worthwhile to study the responses from both
pups.
Comparison of respondents and nonrespondents
is made on the basis of sociodemographic variables
ed on the birth certificates. Respondents were sig-
icantly more likely to be married (87.1 percent for
pondents compared to 69.7 for nonrespondents),
ipondents also were significantly likely to be older
san ages were 26.9 and 25.7 years, respectively),
ite (86.5 percent as compared to 67.4 percent), and
ter educated ( 1 2.9 years of formal education as com-
'ed to 12.0 years) than nonrespondents. No signifi-
it differences were observed between respondents
jJ nonrespondents with respect to county of resi-
dence, parity, birth weight, or seasonality of birth.
Comparison of sociodemographic characteristics for
the inhospital populations showed no statistically sig-
nificant differences on county of residence, maternal
age, maternal education, parity, birth weight, marital
status, race, or seasonality of birth. Multiple births
were significantly more likely to occur in hospitals.
Comparison of sociodemographic characteristics for
the respondents between inhospital and out-of-hospi-
tal births showed no significant differences in marital
status, race, county of residence, maternal age, parity,
birth weight, or seasonality of birth. Mean education
of out-of-hospital mothers tended to be slightly higher
than that of inhospital mothers with a mean number
of years of 13.1 compared to 12.8 years (P > .08).
Conclusions reached on the basis of these responses
should be considered tentative and final conclusions
will have to follow further studies.
Out-of-hospital births were organized into four
categories, based on responses to the questions
“Where was your baby bom?” and "Where had you
planned to have your baby?" These categories were
planned home birth, unplanned home birth, birthing
center birth, and other; “other" included locations
such as automobiles and ambulances.
SERVICES TO BABIES
Questions on services given to babies were designed
to determine whether the babies received those ser-
vices considered part of good child health supervision
appropriate to the age of the child when questioned.
L. 81— NUMBER 7— JULY 1984
551
Questions Regarding your Baby's Birth
Please answer the following questions. Feel free to write any comments on back.
1. Where was your baby bom?
□ a. In a hospital
□ b. At home
□ c. In a birthing center
□ d. Other (please specify)
2. Did you choose to have your baby where it was bom?
□ Yes □ No □ Do Not Know
3. Where had you planned to have your baby bom?
□ a In a hospital
□ b. At home
□ c. In a birthing center
□ d. Other (please specify)
4. Why did you plan to have your baby bom there?
(Please specify, any or all)
□ a Cost was a factor
□ b. Level of independence was a factor
□ c. Desired a home like setting
□ d. Safety was a factor
□ e. Other (please specify)
5. Were you pleased with your birthing experience?
□ Yes □ No □ Do Not Know
6. Would you plan to give birth again in the same place?
□ Yes □ No □ Do Not Know
7. Did the baby have complications at or shortly after
birth?
8. Did you ( the mother) have complications at or shortl
after birth?
□ a No, I (the mother) did not have any
complications.
□ b. Yes, I (the mother) saw a doctor at his office
because of complications.
□ c. Yes, I (the mother) required a hospital stay
because of complications.
□ d. Please specify problem.
9. Did you receive family planning advice after the
baby’s birth?
□ Yes □ No □ Do Not Know
10. Did your baby get an injection to prevent bleeding?
□ Yes □ No □ Do Not Know
11. Did the baby have blood taken (from a heel stick) for
a screening test?
□ Yes □ No □ Do Not Know
1 2. Did your baby have drops placed in his/her eyes to
prevent infection afterbirth?
□ Yes □ No □ Do Not Know
13. Did your baby have its first shot (immunization) by
three months of age?
□ Yes □ No □ Do Not Know
14. Did a nurse or doctor examine the baby and/or you
within one week after birth?
□ Yes □ No □ Do Not Know
□ a. No, the baby did not have any complications. ^
□ b. Yes, the baby saw a doctor at his office because
of complications.
□ c. Yes, the baby required a hospital stay because of 1 6.
complications.
□ d. Please specify problem.
Did a nurse or doctor visit within two weeks?
□ Yes □ No □ Do Not Know
Did you receive an examination within six weeks aftei
the birth?
□ Yes □ No □ Do Not Know
Figure— Questionnaire used by Maternal and Child Health program.
Answers to these questions are summarized in Table
1. These responses show that, according to the per-
ception of the mother, and compared with hospital
births:
Planned and unplanned home births equally were
likely to have received hemorrhagic prophylaxis,
though there was a nonsignificant tendency for
planned home births to receive it. Birthing center
births were significantly more likely to receive it; other
births showed no difference.
There was a tendency for planned home births not
to receive screening tests, although this tendency was
not significant statistically. Unplanned home, birthing
center, and other births showed no difference.
Planned home births were significantly less likely to
have received ophthalmic prophylaxis; other births
and unplanned home births showed no difference;
birthing center births showed a nonsignificant tend-
ency to receive it.
Planned home births were less likely to have begun
immunizations by three months but the difference
was not significant statistically; unplanned home,
birthing center, and other births showed no difference.
Planned home births showed significantly less in-
fant complications; all other births showed no c
ference.
SERVICES TO MOTHERS AND BABIES
Questions on services given to mothers and
mother and child were designed to determine whetl
family planning counseling was given at an cj
propriate time and whether there was appropriate co
tact with health care providers.
The question on a visit by a doctor or nurse with
two weeks of the birth caused some confusion in t|
respondents. It was intended primarily for motht
having out-of-hospital births, and many mothe
having inhospital births were puzzled by it and wrc
questioning comments after their negative response
Answers to questions on services to mothers aj,
children are summarized in Table 2.
These responses show that according to the pt
ception of the mother, and compared with the hospii1
births:
Birthing center births were significantly more lik(
to receive family planning advice; all other types
births showed no difference.
Planned home and birthing center births were si
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
552
ficantly more likely to have the baby examined by a
jrse or doctor within one week; unplanned home
rths showed a nonsignificant tendency to have
laminations and other births showed no difference.
Planned and unplanned home births were signifi-
intly more likely to have a visit by a nurse or doctor
ithin two weeks; birthing center and other births
lowed no difference.
Planned home births were less likely to show the
other receiving an examination by six weeks; though
ot significantly so; all other types of births showed
o difference.
OCIAL AND ECONOMIC QUESTIONS
Some questions were largely social and economic;
lese questions were intended to find the reasons why
;cisions had been made about the birthing ex-
;rience and what future plans were made subsequent
) it. Answers to social and economic questions are
tmmarized in Table 3.
These answers were all subjective judgments; dif-
rences were not tested for significance. However, it
interesting that the most satisfied group was the
irthing center mothers (34 or 100 percent were
eased with their birthing experience and 31 or 9 1 . 1 8
^rcent would plan to give birth in the same place
*ain). Also, there was very high satisfaction with
tanned home births.
ONCLUSION
Since review of the literature shows a paucity of
lformation regarding out-of-hospital births, this
:udy has value as a basis for further exploration. Even
tough the contact and response rates to this survey
d not justify any firm conclusions, there are, however.
indications that there are differences in the services
given to individual groups. Planned home births, for
example, seemed less likely than other groups to have
received ophthalmic prophylaxis and also may have
been less likely to have screening for inborn errors of
metabolism and to have immunizations started by
three months.
It must be remembered that the answers to the ques-
tions in this study reflect mothers’ perceptions of the
care provided during their birth experiences and do
not necessarily show actual provision of services. One
example of this discrepancy can be seen in the area
of hemorrhagic disease prophylaxis which may have
been administered on a regular basis to the hospital
bom infants without awareness on the part of the
mother. The conclusions in this study then would be
that more mothers delivering at birthing centers are
aware of hemorrhagic disease prophylaxis for their
newborns than mothers giving birth at hospitals.
Further studies which might have included review
of hospital records as well as ascertaining perceptions
of mothers and interviews of families, were not done
due to funding limitations.
REFERENCES
1. Mehl LE, Peterson AH, Whitt M, Hawes WE: Outcomes
of elective home births, a series of 1,146 cases. J Repro Med
19:51, 1977.
2. Simmons RS: Who chooses home birth and the impact
of planning status on neonatal mortality and birthweight.
Annual Meeting, American Public Health Association, 1980.
3. Burnett CA Jones JA Rooks J, Tyler CW, Miller CA
Home delivery and neonatal mortality in North Carolina An-
nual Meeting, American Public Health Association, 1977.
4. Personal communication, Charles Karkut, Vital
Statistics Registrar, New Jersey.
pL. 81— NUMBER 7— JULY 1984
553
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets —
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE- DAILY
LONG ACTING mg mg mg
CAPSULES
The appearance of
INDERAL LA
capsules is a registered
trademark ot
Ayerst L aboratories
Ayerst]
lilt
ONCE-DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE ,
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERAL LA iii
LONG ACTING
CAPSULES
80
mg
120
mg
160
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA Is available as 80 mg, 120 mg, and 160 mg capsules,
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 1 0 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol |
may increase oxygen requirements by increasing left ventrtcular fiber length, end diastolic ff
pressure and systolic ejection period The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity
In dosages greater than required for beta blockade. INDERAL also exerts a quinidme-like
or anesthetic-like membrane action which affects tiro cardiac action. potential The signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect ol propranolol has not beensestablished Beta-
adrenergic receptors have been demonstrated in the plat vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital For example“in paffents with seve'ely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking tig
prior to major surgery is controversial. It should be noted, however, that the impaired all
the heart to respond to reflex adrenergic stimuli may augment the risks of general anet;i$
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor oljii
receptor agonists and its effects can be reversed by administration of such agents!
dobutamine or isoproterenol. However, such patients may be subject to protracted k
hypotension. Difficulty in starting and maintaining the heartbeat has also been reporte;*v
bets blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent tt ai
pearance of certain premonitory signs and symptoms (pulse rate and pressure chancffl
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may boo
difticult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthvrca
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sym n
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function;!
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have,*
reported in which, after propranolol, the tachycardia was replaced by a severe brady d
requiring a demand pacemaker. In one case this resulted after an initial dose oFt
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with im k
hepatic or renal function. INDERAL is not indicated for the treatment of hypertun
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pi|i
should be told that INDERAL may interfere with the glaucoma screening test. Withdraw.'
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart di:
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered. The added catechol: I
blocking action may produce an excessive reduction of resting sympathetic nervous £ I
which may result in hypotension, marked bradycardia, vertiqo, syncopal attacks, or orthc 9
hypotension.
Carcinogenesis, Mutagenesis, Impairment of Fertility. Long-term studies in animal; I
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stud]
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sign a
drug-induced toxicity There were no. drug-related tumorigenic effects at any of the d' c
levels Reproductive studies in animals did not show any impairment of fertility thr :
attributable to the drug
Pregnancy Pregnancy Category C \Di RAI has been shown to be embryotc
animat studies at doses about 10 times greater than the maximum recommended human
There are no adequate and weti-controlled studies in pregnant women INDERAL s
be used during pregnancy only if the potential benefit justifies the potential risk to the
Nursing Mothers INDERAL is excreted in human milk Caution should be exercised
. INDERAL is administered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive treart failure, intensification of AV block,
tension: paresthesia of hands; thrombocytopenic purpura arterial insufficiency, usually
Raynaud type
Central Nervous System lightheadedness; mental depression manifested by msc
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia,
disturbances; hallucinations; an acute reversible syndrome characterized by disoriental
time and place, short-term memory loss, emotional lability, slightly clouded sensoriurr
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diat:
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with a< '
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytoji
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has if
reported.
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male h
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous rea. f
involving the skin, serous membranes and conjunctivae reported for a beta blocker (prai :
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloric i
sustained-release capsule for administration once daily. If patients are switched from IND !
tablets to INDERAL LA capsules, care should be taken to assure that the desired therai I
effect is maintained INDERAL LA should not be considered a simple mg for mg substitijli
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitratio
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inift
HYPERTENSION — Dosage must be individualized The usual initial dosage is £|
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage rrv:
increased to 120 mg once daily or higher until adequate blood-pressure control Is ach; i
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage 1 1
mg may be required The time needed for full hypertensive response to a given dos;
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDER/H
once daily, dosage should be gradually increased at three to seven day intervals until opt ]
response is obtained Although individual patients may respond at any dosage lever
average optimum dosage appears to be 160 mg once daily In angina pectoris, the valuh
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few vf>
(see WARNINGS).
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDER/i-
once daily. The usual effective dose range is 160-240 mg once daily The dosage m. |
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response ji1
obtained within four to six weeks after reaching the maximum dose, INDERAL LA th[f
should be discontinued It may be advisable to withdraw the drug gradually over a per 1
ssvsrsl weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily. |
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group ajf
limited to permit adequate directions for use
‘The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laborai "
8830
AYERST LABORATORIES
MyerSlY New York, N.Y. 10017
556
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI;
[1a.se Report:
\lcoholic Cardiomyopathy
[STVAN A. GASPAR, M.D. ENGLEWOOD*
A 12-year , two-pints whisky drinker developed cardiac failure.
Fairly extensive degeneration and liquefaction of the sarcoplasm
\pfthe myocardialfiberSf necrosis of myocardial fibers, and
fibrosis were seen with light microscopy. Cardiomyopathy was
\a direct effect of excessive alcohol on the myocardium.
The direct action of alcohol on the
myocardium was not seriously
considered until about the
id-20th century; yet it was recognized much earlier
at alcohol causes myocardial damage. Today, al-
'holic damage of the myocardium is designated as
coholic cardiomyopathy. Alcoholism is frequent and
t the opportunity for histologic study of hearts from
coholic cardiomyopathy is rare.
Light microscopic changes of the myocardium in
{coholic cardiomyopathy were thought to be unim-
essive. However, reports of such studies are few. It
is been found that only a number of alcoholics will
velop alcoholic cardiac pathology, i.e. eardio-
yopathy.
A case of fatal alcoholic cardiomyopathy occurred in
380 at Englewood Hospital. The observed light miero-
j'opic pathological changes are worth reporting to
llarge our knowledge of the subject.
\SE REPORT
The patient was a 32-year-old, thin and dehydrated
lack male, a known alcoholic for 12 years, who drank
m pints of whisky every day. At admission on Febru-
y 17, 1980, he complained of a cold and cough with
igue pain across his chest, but no fever or chills,
epatomegaly and scleral icterus were obvious. The
ngs were clear; respirations, 24/min; temperature,
7.4° F.(p.o.); and pulse, 146 and regular. Blood pres-
sure was 100/70. There were no heart murmurs. The
abdomen was distended. The reflexes were hypoaetive
and there was a very mild tremor. There was no
evidence of gastrointestinal bleeding. Chest x-ray
showed marked cardiac enlargement, congestive heart
failure, fluid at the left base, and hepatomegaly.
He was treated with intravenous fluids containing
sodium bicarbonate and thiamine.
Laboratory work on February 17, 1980, showed RBC,
3,500.000; Hgb, 1 1 gm/dl; WBC, 10,900; and 80% polys.
Blood glucose was 125 mg/dl; uric acid, 18.0 mg/dl;
total protein, 6.5 gm/dl; total bilirubin, 3.0 mg/dl; LDH,
1,300 units; SGOT, 1,000 units; and lipase, 1.0 unit.
Urinalysis showed 3 + protein, and bile was positive.
On Feburary 18, 1980, the patient was in shock
(blood pressure was 38/30). Cardiac arrest developed,
but he was resuscitated. The serum pH was 7.01. On
February 19, 1980, he became comatose and apneic.
Laboratory reports showed serum pH, 6.9; and P02, 36
mm/Hg. A blood sample was negative for meth-
ylaleohol. In spite of vigorous treatment, he expired.
Postmortem examination was performed 20 hours
after death. The peritoneal cavity contained 1,000 cc
of ascitic fluid. There were 700 cc of left chest fluid.
800 cc of right chest fluid, and 90 cc of pericardial
fluid. The lungs were markedly expanded, congested,
*From the Department of Pathology. Englewood Hospital. Cor-
respondence may be addressed to Dr. G&sp&r, 261 Glenwood
Road, Englewood, NJ 07631.
0L. 81— NUMBER 7-UULY 1984
557
Figure 1— In the center of the field (arrows) there are necrotic
myocardial fibers. Many of the other fibers show longitudinal
sarcoplasmic degenerations, vacuoles and, particularly in the
right half of the field, many thin, wavy, thread-like, and some
fragmented fibers. (H&E, low magnification, 10 x NA .25)
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE1
Figure 4 — Degenerating segments of myocardial fibers w
marked disruption of the myofibrils. A horse tail-like stn
ture is produced (arrow). (H&E, high magnification, 45 x N:
.66)
* m .
Figure 2 — Small fibrous patch formed at site of myocardial
necrosis. (H&E, high magnification, 45 x NA .66)
Figure 3 — Small segmental liquefaction of myocardial fibers
with disruption of the myofibrils (arrow). (H&E, high magnifi-
cation, 45 x NA .66)
and heavy. The parenchyma was dark grayish:red,
doughy, and very edematous. Culture was negative for
pathogenic organisms. The heart weighed 420 gm.
There was hypertrophy and dilatation of all chambers,
particularly that of the right auricle and of both ven-
tricles. Thrombus filled the right auricular appendage.
The coronary arteries and the aorta showed only a few
small fatty intimal spots. The myocardium was flabby,
grayish-red, without grossly recognizable spots of
fibrosis. The liver was slightly enlarged, weighing 1,835
gm. It was hard, reddish-yellow with faintly micro-
Figure 5 — Elongated sarcoplasmic degenerations with spl
ting of the myocardial fibers into thin strands (arrows). (H&
high magnification, 45 x NA .66)
granular capsular surface. The gastrointestimj
mucosa was edematous.
LIGHT MICROSCOPIC STUDY
There were multiple scattered recent segment;
necroses of myocardial fibers (Figure 1). The necroti:
fibers broke up into larger masses of debris and als
into small homogeneous granular particles. All thes
disappeared, became absorbed, leaving a space i
which lymphocytes and phagocytic cells were demor
strable. There were scattered larger foci of stromal co
lapse and early fibrous replacement, taking the plaolj
of the almost entirely absorbed areas of myocardif
necrosis (Figure 2). In many other areas there wer
myocardial fibers with segmental liquefaction of th
sarcoplasm and with disorganization of the myofibril
(Figure 3). If a larger segment of the myocardial fibe
was involved with the liquefaction of the sarcoplasn
a horse tail-like structure was formed by the disrupte
myocardial fibrils (Figure 4). Or, if the sarcoplasmi.
liquefaction involved multiple adjacent myocardit
fibers, the cohesion of the myofibrils became so dis
rupted that only a structure similar to a bunch of hair
remained. When the myofibers were sectioned long)
tudinally, numerous longitudinal clear spaces or split
of varying size became apparent (Figure 5). On trans'
verse sections these sarcoplasmic liquefactions an<
degenerations appeared as vacuoles. This type of de
558
feneration of the sarcoplasm was fairly widespread
id it seemed that in multiple areas a sizeable per-
entage of the myocardial fibers was affected in this
ash ion.
The liver showed very marked eentrilobular passive
ongestion. Fatty changes were extensive. Mallory bod-
?s were not demonstrable. Histology of the lungs cor-
esponded with the gross pathological findings.
DISCUSSION
Since the 1960s. it has been appreciated that ex-
essive alcohol intake may result in myocardial dam-
Ige independent of malnutrition or thiamine deficien-
v or both. However, in 1884, Bollinger of Munich ree-
ignized the relationship between heavy beer drinking
md cardiac hypertrophy and cardiac dilatation; he
onsidered the latter as toxic manifestation of habitual
>eer alcoholism.1 Alexander2 and Gould3 stated that
he myocardial changes in alcoholic cardiomyopathy
i >y light microscopy usually were focal, minimal, and
>ut of proportion to the severity of the clinical findings.
Jaeuolation of myocardial fibers was described by
lloor.4 In my observation, the vacuoles occurred as
uch when the myocardial fibers were sectioned trans-
'ersely and appeared anywhere in the myocardial
ibers. They were the cross sections of the longitudinal
iarcoplasmic degenerations of the myocardial fibers.
Our patient’s histoiy fulfills the criteria of Brigden5
md puts his heart disease into the category of toxic
ardiomyopathy. The important pathology was a fairly
widespread segmental degeneration and liquefaction
>f the sarcoplasm of the myocardial fibers. The absence
>f necrotic myocardial fibers was stressed in several
tlrertinent publications, but myocardial necrosis oc-
I
I
i
curred in our patient. These degenerative changes are
the result of the direct toxic action of alcohol on the
myocardium. The irregularly thinned-out and often
wavy myocardial fibers are not caused by atrophy but
are caused by the longitudinal liquefaction of the
sarcoplasm, which splits the myocardial fibers into
multiple strips and, at times, into irregular-sized thin
strands.
Damaging effects of excessive amounts of alcohol on
the myocardium were demonstrated experimentally in
mice and rats by Burch6 and Maines.7 The 12-year
histoiy of heavy alcohol abuse of our young patient is
well within the 12- to 15-year time lapse when al-
coholic cardiomyopathy develops. His death occurred
as a result of congestive heart failure, i.e. pump failure
as a consequence of alcoholic cardiomyopathy.
REFERENCES
1. Bollinger P: Ueber die haufigkeit und ursaehen der
idiopathisehen herzhypertrophien in Miinchen. Deutsche
Medicinische Wochenschrift 10:180-181, 1884.
2. Alexander CS: Idiopathic heart disease. 11. Electron
microscopic examination of myocardial biopsy specimens in
alcoholic heart disease. Am J Med 41:229-234, 1966.
3. Gould L: Cardiac effects of alcohol. Am Heart J
79:422-425, 1970.
4. Bloor CM: Cardiac Pathology. New York, NY, J.B. Lippin-
cott Co. 1978.
5. Brigden W: Alcoholic cardiomyopathy. Cardiovasc
Clinics 4(1):188-201, 1972.
6. Burch GE, Colcolough HL, Harb JM, Tsui CY: The effect
of ingestion of ethyl alcohol, wine, and beer on the
myocardium of mice. Am J Cardiol 27:522-528, 1971.
7. Maines, JE, Aldinger EE: Myocardial depression accom-
panying chronic consumption of alcohol. Am Heart J
73:55-63, 1967.
IOh. 81— NUMBER 7— JULY 1984
559
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562
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSi
Case Report: Tracheoesophageal fistula
\nd Arteriosclerotic Aortic Aneurysm
Raymond Schiffman, m.d., camden*
An arteriosclerotic aneurysm of the thoracic aorta compressed
the midesophagus. The pulsating aneurysm caused traumatic
ulcers of the anterior and posterior walls of the esophagus. The
ulcer in the anterior wall perforated into the lower trachea
producing a tracheoesophageal fistula and bronchorrhea.
Most acquired fistulas between
the esophagus and tracheo-
bronchial tree result from
:arcinoma.‘ Review of acquired nonmalignant esoph-
igorespiratoiy fistulas have emphasized infection and
rauma as the chief causes.1 3 In the case report de-
scribed, a tracheoesophageal fistula formed as a result
)f repetitive trauma of the esophagus and trachea from
i pulsating arteriosclerotic aortic aneuiysm.
ZASE REPORT
A 73-year-old white woman had a long history of
iysphagia, which progressed to the point where she
:ould swallow only liquids. She lost an unspecified
imount of weight. Two days prior to admission to the
lospital she became markedly dyspneic, developed a
lonproductive cough, and refused to eat. Her syrnp-
oms did not improve after treatment with doxycycline
md an antitussive agent and she was admitted to the
lospital.
She was being treated for hypertension, pulmonary
imphysema, a gastric ulcer, and a hiatal hernia Gall-
bladder and cataracts from each eye had been removed
breviously. She had smoked 30 cigarettes a day for 50
^ears. Her son and mother had diabetes mellitus; her
lusband had been treated for tuberculosis.
On physical examination, her blood pressure was
132/78; her pulse, 142/minute; respirations,
32/minute; and rectal temperature, 97° F. Breath
sounds were diminished in the right chest and ex-
piratory wheezes were noted. The feet were cyanotic.
No significant changes from previous x-rays were
noted in a chest film. An electrocardiogram showed a
supraventricular tachycardia with probable old in-
ferior wall myocardial infarction, right bundle-branch
block, and left anterior fascicular block.
Significant laboratory determinations included a
hemoglobin of 11.3 gm/dl; a hematocrit of 34.7%; a
fasting blood sugar of 321 mg/dl; a blood urea nitrogen
of 54 mg/dl; and a creatinine of 3.3 mg/dl.
After being intubated she coughed up a large plug
of mucus and then had copious serous secretions from
the tracheobronchial tree. She was treated with
aminophylline and verapamil but had to be placed on
a respirator because of increasing respiratory distress
and marked bronchorrhea A culture of sputum grew
normal flora. A blood culture was sterile. A urine cul-
ture grew a Proteus species in significant numbers and
she was treated with Cefoxiten® and erythromycin.
On the second hospital day, a chest film was taken
after a silicone feeding tube was passed and revealed
the tube in the right pleural space (Figure 1). On the
lateral view, a mass was noted behind the lower
*Dr. Schiffman is Acting Chief, Department of Pathology,
Cooper Hospital/University Medical Center, Camden. Cor-
respondence may be addressed to Dr. Schiffman, Cooper Hos-
pital/University Medical Center, One Cooper Plaza, Camden,
NJ 08103.
IOL. 81— NUMBER 7— JULY 1984
563
Figure 1— Chest film revealing silicone feeding tube in right
pleural space.
trachea Carbenieillin, tobramycin, and clindamycin
were administered to combat mediastinitis.
The patient developed abdominal pain and her
hemoglobin dropped to 6.7 gm/dl. Her dyspnea became
more severe. Candida tropicalis was cultured from the
sputum. Cells suspicious but not diagnostic for small
cell carcinoma and cells suspicious of herpesvirus in-
fection were noted in smears of sputum. A chest x-ray
revealed bilateral basilar infiltrates with an alveolar
pattern which was more pronounced on the right. The
preterminal course was characterized by marked
bronchorrhea and hypotension which required the ad-
ministration of pressor agents. Massive pulmonaiy
edema did not respond to furosemide therapy. By the
ninth hospital day, she developed a markedly dis-
tended abdomen and a temperature of 101.2°F and
died. Permission for autopsy was granted.
RESULTS
The immediate cause of death was a 1 cm sharply
circumscribed ulcer in the posterior wall of the distal
gastric antrum which perforated the gastric wall into
the lesser sac and head of the pancreas. Pneu-
moperitoneum accounted for the abdominal disten-
tion. In the gastric body were a few additional small
superficial ulcers.
Pulmonary emphysema and bronchiectasis were
complicated by acute bronchitis with aspirated blood,
acute pulmonary edema, and bilateral pleural ef-
fusions. There was no evidence of tuberculosis.
Arteriosclerotic cardiovascular disease was mani-
fested by an old occlusion of the right coronary artery
accompanied by old subendocardial infarcts of the
Figure 2 — Aneurysm of descending thoracic aorta — opei
and viewed from behind.
diaphragmatic wall of the left ventricle and tip of t
anterior papillary muscle both of which showed rece
extensions. The aorta showed severe atherosclero*
with numerous calcified intimal plaques and adhere
mural thrombi. One of these plaques partially occlud
the left renal artery and caused atrophy of the 1<
kidney which weighed 60 gm. Atheromatous embi
were found in the kidneys, spleen, pancreas, stomac
small bowel, liver, urinary bladder, uterus, adrer
glands, and vertebrae. In the kidneys and spleen the
were accompanied by small infarcts. In the descends
thoracic aorta was an aneurysm measuring 6 cm
diameter which bulged from the anterior wall and cor
pressed the posterior wall of the midesophagus (Figu
2). The esophageal mucosa over this area was i
eerated. At the same level as this ulcer on the posteri
wall of the esophagus was a 3 cm perforating ulcer c
the anterior wall which extended into the posteri'
wall of the trachea just above the carina to create
tracheoesophageal fistula (Figures 3 and 4). f
esophageal diverticulum was noted and no enlargf
perihilar lymph nodes were found.
On microscopic examination, the aneurysm showr
thinning and destruction of the media with numeroi
large deposits of cholesterol crystals and a large mur
thrombus. There was little or no inflammation, r
granulomas or giant cells, and no evidence of en>
arteritis of vasa vasorum. The esophageal ulcer ar
tracheoesophageal fistula showed superficial cc
onization by yeast-like organisms resembling Ca
dida species which did not extend deeply into tf
tissue. At the margin of the ulcerated area were raj
multinucleated epithelial cells with ground glass ni
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE;
564
clei suggestive of herpesvirus infection. Inclusion bod-
ies were not found. There was no evidence of tumor
and the ulcerated areas displayed only necrosis and
hemorrhage. A vein near the fistula contained an or-
ganized thrombus.
COMMENT
The kissing-type ulcers of the midesophagus occur-
ring at the same level as the aneurysm of the thoracic
aorta suggested that the ulcers were caused by repeti-
tive collisions of the anterior and posterior walls of the
esophagus due to pulsation of the aneurysm. Despite
the presence of cells suspicious for tumor in the
aspirated sputum, there was no evidence of neoplasm
in multiple microscopic sections of the fistula. Most of
the causes of acquired nonmalignant esophagores-
piratoiy fistulas enumerated by Wychulis et al.1 were
not found. In particular, there was no clinical or
pathologic evidence of tuberculosis, syphilis, ac-
tinomycosis, or diverticulum of the esophagus. In spite
of the history of hiatus hernia, reflux esophagitis as
a cause of esophageal ulcers and fistula is excluded by
the location of the fistula in the midesophagus and the
nonuleerated condition of the lower esophagus.
The presence of numerous Candida organisms in
the fistula is a not unexpected finding in a diabetic
patient treated with multiple antibiotics. These yeasts
frequently colonize dead or dying tissue.
The presence of a few multinucleated giant cells with
ground glass nuclei both in the sputum and autopsy
sections of the fistula suggests herpesvirus infection.
Herpetic esophagitis is a common cause of esophageal
ulceration4 and generally is regarded as an op-
portunistic infection occurring in debilitated patients
particularly in those suffering from neoplastic disease
and especially in the immunocompromised. However,
esophageal trauma also has been recognized as a
predisposing factor.5 It is well known that cutaneous
herpes infections have a predilection for traumatized
areas68 and tracheal trauma has been implicated as a
predisposing factor in eases of herpetic tracheo-
bronchitis and pneumonia.9 In the esophagus, the
trauma usually is from a nasogastric tube but there
is no reason to exclude trauma caused by the pulsating
aneurysm in this case. Concomitant herpes and
mondial esophagitis previously have been re-
ported.41011
The few aneurysms of known cause that have been
reported previously in association with tracheo-
esophageal fistulas have been caused by syphilis.13 12 14
Unfortunately, a serologic test for syphilis was not per-
formed in this patient. However there was no evidence
of syphilitic aortitis and in particular no evidence of
endarteritis of the vasa vasorum of the aorta, miliary
gummas, aortic valvular insufficiency with widened
commissures or stenosis of coronary artery ostia. The
advanced age of the patient, the presence of severe
generalized arteriosclerosis, and the pathologic fea-
tures of the aneurysm speak for an arteriosclerotic
aneurysm. Although arteriosclerotic aneurysms are
more common in the abdominal aorta, 20 percent of
such aneurysms are located in the thoracic aorta.15
Several cases of dysphagia caused by esophageal com-
pression by an aortic aneurysm 1617 or a tortuous
aorta18 have been reported.
'igure 3 — Aneurysm and posterior wall of esophagus defleet-
d to left revealing tracheoesophageal fistula involving an-
erior wall of esophagus.
'Igure 4 — Trachea opened anteriorly revealing tracheo-
sophageal fistula involving posterior wall.
rOL. 81— NUMBER 7— JULY 1984
565
SUMMARY
Although dysphagia preceding an acquired
tracheoesophageal fistula in an elderly patient sug-
gests esophageal or bronchial cancer, in the absence
of a tumor, the possibility of thoracic aneuiysm as the
cause of the fistula should be kept in mind.
REFERENCES
1. Wyehulis AR Ellis FH Jr, Anderson HA Acquired non-
malignant esophagotracheobronchial fistula. JAMA
196:117-122, 1966.
2. Coleman FP, Burch GH Jr: Acquired nonmalignant
esophagotracheobronchial fistula. J Thorac Surg 19:542-558,
1950.
3. Clagett OT, Payne JH, Moersch HJ: Acquired
esophagotracheobronchial fistula Surg Gynecol Obstet
82:87-90, 1946.
4. Nash G, Ross JS: Herpetic esophagitis, a common cause
of esophageal ulceration. Hum Pathol 5:339-345, 1974.
5. Berg JW: Esophageal herpes: A complication of cancer
therapy. Cancer 8:731-740, 1955.
6. Findlay GM, Mac Callum FO: Recurrent traumatic
herpes. Lancet 1:259-261, 1940.
7. Stem H, Elek SD, Millar DM, et al.: Herpetic whitlow: A
form of cross-infection in hospitals. Lancet 2:871-874, 1959.
8. Foley FD, Greenawald KA, Nash G, et al.: Herpesvirus
566
infection in burned patients. N Engl J Med 282:652-6! ,
1970.
9. Nash G: Necrotizing tracheobronchitis and broncl
pneumonia consistent with herpetic infection. Hum Patl1
3:283-291, 1972.
10. Rosen PR Hajdu SI: Visceral herpes-virus infections |
patients with cancer. Am J Clin Pathol 56:459-465, 197
11. Mirra SS, Byran JA Butz WC, et al.: Concomitc|
herpes-monilial esophagitis: A case report with ult
structural study. Hum Pathol 13:760-763, 1982.
12. Moersch HJ, Tinney WS: Fistula between I
esophagus and the tracheobronchial tree. Med Clinics No
Am 28:1001-1007, 1944.
13. Davidson PB, Mills ES: Fistulae between the esophap
and the respiratory tract. Med Clinics North Am 7:999-10
1923.
14. Domer G: Broncho-oesophagealfistel bei aortc
aneurysma Dtsch Med Wochenschr 39:400-401, 1913.
15. Blakemore AH, Voorhees AB: Aneurysm of the aorta
review of 365 cases. Angiology 5:209-231, 1954.
16. Pezzella AT, Brown BE, Walls JT, et al.: Esophag,
obstruction secondary to a tortuous aortic aneuiysm. C;
report. Missouri Med 78:193-195, 1981.
1 7. Sakiyalak P, Bellon EM, David P, et al.: Esophageal (
struction due to saccular aneurysm of the distal thora.
aorta J Thorac Cardiovasc Surg 64:959-962, 1972.
18. Hanna EA Derrick Jr, Dysphagia caused by tortuos|
of the thoracic aorta J Thorac Cardiovasc Surg 57:134-R
1969.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
BALANCED
CALCIUM
<ow incidence of side effects
1ARDIZEM® (diltiazem HC1)
roduces an incidence of adverse
eactions not greater than that
eported with placebo therapy,
hns contributing to the patient’s
ense of well-being.
rdizem is indicated in the treatment of angina pectoris due to
ronaiy artery spasm and in the management of chronic stable
gina (classic effort-associated angina) in patients who cannot
erate therapy with beta-blockers and/or nitrates or who remain
mptomatic despite adequate doses of these agents.
ferences:
Strauss WE, McIntyre KM, Parisi AE, et al: Safety and efficacy
of diltiazem hydrochloride for the treatment of stable angina
pectoris: Report of a cooperative clinical trial. Am J Cardiol
49:560-566, 1982. "
Pool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise-
inducible chronic stable' angina with diltiazem: Effect on treadmill
axercise. Chest 78 (July suppl):234-238, 1980.
Reduces angina attack frequency
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test,2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (PC.005).
CARDIZEM
(diltiazem HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
Please see full prescribing information on following page.
PROFESSIONAL USE INFORMATION
cardizem
(dilhazem HCI)
30 mg and 60 mg tablets
DESCRIPTION
CARDIZEM® (diltiazem hydrochloride) is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist). Chemically,
diltiazem hydrochloride is 1 ,5- Be nzoth iazepi n-4(5H )one ,3-(acetyloxy)
-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+) -cis-.The chemical structure is:
Diltiazem hydrochloride is a white to off-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform.
It has a molecular weight of 450.98. Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administration.
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle.
Mechanisms of Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovine-induced cor-
onary artery spasm are inhibited by CARDIZEM,
2. Exertional Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads.
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect. The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases in peripheral resistance.
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrioventricu-
lar conduction In isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate-blood pressure product for any given work load.
Studies to date, primarily in patients with good ventricular function,
have not revealed evidence of a negative inotropic effect; cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
of diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater than first-degree
AV block. Diltiazem-associated prolongation of the AH interval is not
more pronounced in patients with first-degree heart block. In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine. In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins. Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxin, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration. The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours. Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem. Therapeutic blood levels of
CARDIZEM appear to be in the range of 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given; a 120-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem.
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment of spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM has been effective in controlled trials in
reducing angina frequency and increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a functioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1. Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome. This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0 48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2. Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited. Caution should
be exercised when using the drug in such patients.
3. Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4. Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals. The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued. In dogs,
doses of 20 mg/kg were also associated with hepatic changes;
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated. Available data are not sufficient, however, to predict
the effects of concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities. In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21 -month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests. No intrinsic effect on fertility was observed
in rats.
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women; therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition. In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are: edema (2.4%),
headache (21%), nausea (1.9%), dizziness (1.5%), rasi
asthenia (1.2%), AV block (1.1%). In addition, the follow)
were reported infrequently (less than 1%) with the order of ;
tion corresponding to the relative frequency of occurrena
Cardiovascular:
Nervous System:
Gastrointestinal:
Dermatologic:
Other:
Flushing, arrhythmia, hypotension, ),
dia, palpitations, congestive heai
syncope.
Paresthesia, nervousness, sorr
tremor, insomnia, hallucinations, anc
Constipation, dyspepsia, diarrhea,
mild elevations of alkaline phosphate
SGPT, and LDH.
Pruritus, petechiae, urticaria, photo:
Polyuria, nocturia.
The following additional experiences have been noted:
A patient with Prinzmetal's angina experiencing ep
vasospastic angina developed periods of transient asyr
asystole approximately five hours after receiving a sine
dose of CARDIZEM
The following postmarketing events have been repoi
quently in patients receiving CARDIZEM: erythema multifi
kopenia; and extreme elevations of alkaline phosphata;
SGPT, LDH, and CPK. However, a definitive cause and effec
these events and CARDIZEM therapy is yet to be establi:
OVERDOSAGE OR EXAGGERATED RESPON5
Overdosage experience with oral diltiazem has bee'
Single oral doses of 300 mg of CARDIZEM have been well
by healthy volunteers. In the event of overdosage or ex,
response, appropriate supportive measures should be en
addition to gastric lavage. The following measures may be cr
Bradycardia
High-Degree AV
Block
Cardiac Failure
Hypotension
Administer atropine (0.60 to 1.0 me
is no response to vagal blockade, i
isoproterenol cautiously.
Treat as for bradycardia above. Fi
degree AV block should be treated
diac pacing.
Administer inotropic agents (isopi
dopamine, or dobutamine) and diure
Vasopressors (eg, dopamine or lev
bitartrate).
Actual treatment and dosage should depend on the seve
clinical situation and the judgment and experience of tin
physician
The oral/LD50’s in mice and rats range from 415 to 7<
and from 560 to 810 mg/kg, respectively. The intravenous
these species were 60 and 38 mg/kg, respectively. The or
dogs is considered to be in excess of 50 mg/kg, while letl
seen in monkeys at 360 mg/kg. The toxic dose in man is n
but blood levels in excess of 800 ng/ml have not been a
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atheroscleroi
nary Artery Disease or Angina Pectoris at Rest Due
nary Artery Spasm. Dosage must be adjusted to each
needs. Starting with 30 mg four times daily, before met
bedtime, dosage should be increased gradually (given
doses three or four times daily) at one- to two-day inter
optimum response is obtained. Although individual pati
respond to any dosage level, the average optimum dos;
appears to be 180 to 240 mg/day. There are no available dat,
ing dosage requirements in patients with impaired renal tj '
function. If the drug must be used in such patients, titration
carried out with particular caution.
Concomitant Use With Other Antianginal Agents
1. Sublingual NTG may be taken as required to aha:?
anginal attacks during CARDIZEM therapy.
2 Prophylactic Nitrate Therapy -CARDIZEM may
coadministered with short- and long-acting nitrates,:
have been no controlled studies to evaluate the af
effectiveness of this combination.
3. Beta-blockers. (See WARNINGS and PRECAUTIONS
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles of
0088-1771-47) and in Unit Dose Identification Paks of
0088-1771-49). Each green tablet is engraved with MARIC n
side and 1771 engraved on the other. CARDIZEM 60-n«
tablets are supplied in bottles of 100 (NDC 0088-1772-47) rid
Dose Identification Paks of 100 (NDC 0088-1772-49). Ec "
tablet is engraved with MARION on one side and 1772 on
Issue
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES. INC
KANSAS CITY, MISSOURI 64137
Clinical Note:
Iuided Blind Endotracheal Intubation
Jay Jong il Choi, m.d., Marcelino Potian, m.d., Eun Ye Yoo, m.d., Wen-hsien Wu, m.d., Newark*
A modified method of blind endotracheal intubation used in a
tracheostomized patient is presented. Advantages in
simultaneous airway and ventilatory control without the use of
muscle relaxants and without the need of an expensive flexible
fiberoptic laryngoscope are described.
— —
,
Insertion of a phrenic nerve
pacemaker for a quadriplegic
patient presents difficult prob-
Ijns to anesthesiologists. The use of a guided blind
(dotraeheal intubation technique is illustrated in a
[Itient with pre-existing tracheostomy. We are de-
slribing a modified Waters’s technique1 for intubation.
USE REPORT
|A. forty- five-year old dependent quadriplegic patient
|th a tracheostomy of a one-year duration was sched-
ibd for insertion of phrenic nerve pacemaker. The
] tient had ankylosis of both temporomandibular
jints with marked limitation of mouth opening (2.5
( 1). The cervical spine was markedly angulated ( 1 20°)
i the old fracture site.
A sterile suction catheter was inserted through the
Ueheostomy stoma and orophaiynx into the mouth.
I An endotracheal tube was threaded over the distal
< d of this catheter which served as a guide and ad-
need into the trachea while holding the proximal
ijtheter end at the stoma (Figure).
The bevel of the tracheostomy tube was reinserted
'rough the stoma for assisted ventilation. When the
dotraeheal tube was advanced to the level of the
)ma, the tracheostomy tube was removed, the en-
( tracheal tube was advanced further into the trachea,
d the cuff was inflated and the airway was secured
I' surgery.
DISCUSSION
It goes without saying that intubation in a patient
with tracheostomy usually is performed through the
stoma if needed.
However, there are situations when oral or nasal
intubation is needed with pre-existing tracheostomy.
A quadriplegic patient who requires insertion of a
phrenic nerve pacemaker presents unique problems to
anesthesiologists. The patient needs to remain con
scious in order to respond to optimal pacemaker out-
put. Muscle relaxants should be avoided to allow
identification of the phrenic nerves and to prevent
hyperkalemia from depolarizing agents. The technique
of guided blind tracheal intubation which was first
described by Waters' is as follows:
A wide-bore needle is inserted cephalad through the
crico thyroid membrane percutaneously. A thin poly-
ethylene catheter next is passed through the needle
and then advanced between the vocal cords into the
nostril (or mouth). A tracheal tube is threaded over it
and advanced into the trachea. Minor modifications of
Waters’s technique have been reported.2 1
The complications of guided blind endotracheal in-
tubation were described by Akinyemi.2 They included
*From (he Department of Anesthesiology, UMDNJ-New Jersey
Medical School. Correspondence may be addressed to Dr.
Choi, UMDNJ-New Jersey Medical School, 100 Bergen Street.
Newark, NJ 07103.
)L. 81— NUMBER 7— JULY 1984
569
Figure — Line drawing of a guided blind endotracheal intuba-
tion. Illustration by Anita A. Lesko, B.S.N., RN.
bleeding, breath-holding, respiratory obstruction, f
fieulty in securing the distal end of the catheter i
using a hook, and loss of the hook.
We concluded that a modified Waters’s technique n
tracheal intubation in the tracheostomized pati.i
was extremely helpful. This method allows intubatr
and airway control through the tracheostomy tva
simultaneously. It does not negate the value of intu -
tion aided by a flexible fiberoptic laryngoscope.
SUMMARY
This modified method of blind endotracheal intu !
tion has advantages in simultaneous airway and v
tilatoiy control without the use of muscle relaxatj
and without the need of an expensive flexible fiberop
laryngoscope.
REFERENCES
1. Waters DJ: Guided blind endotracheal intubation r
patients with deformities of the upper airway. Anaesthei
18:158-162, 1963.
2. Akinyemi OO: Complications of guided blind
dotracheal intubation. Anaesthesia 34:590-592. 1979.
3. Scurr C: A complication of guided blind intubatii.
Anaesthesia 30:41 1-412, 1975.
4. Akinyemi OO, John A: A complication of guided bl
intubation. Anaesthesia 29:733-735, 1974.
|
1
i
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSIj
570
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VOL. 81— NUMBER 7— JULY 1984
571
ran&lTOI THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, CA 90057
For Full Prescribing Information, Please See PDR.
REFER TO
PDR
Android 510 25
Methyltestosterone U.S.R Tablets
Androidvf
Fluoxymesterone U.S.R Tablets, 10 mg
Clinical Note: Adverse Drug Reaction after
Administration of Influenza Vaccine
Robert Solomon, m.d., and John Morlino, d.o., union*
Mary Martucci, r.n., and Dolores Ney, r.n., Elizabeth**
The hepatic cytochrome P-450 enzyme can be impaired by
influenza vaccine. This may cause altered drug metabolism and
exaggerated side effects , especially in the elderly. Physicians
should be aware of this problem and reduce the dosage or replace
drugs which may be so affected.
The influenza vaccine is a recent
and valuable addition to our
medical armamentarium,
unong the current recommendations for its use in-
lude vaccination of the elderly and those suffering
rom chronic illness. These two population groups
lave a high probability of receiving one or more medi-
ations on a regular basis and also have a higher than
verage incidence of adverse drug reactions.1 Several
rticles describe the depressant effect of influenza vac -
ine on the drug metabolizing capacity of the
ytochrome P-450 enyzme system.23 This enzyme sys-
em is a key pathway for the metabolism of many medi-
ations.4 The depression of functional capacity in the
ytochrome P-450 system will result in high serum
,?vels of medications metabolized via this system. The
ytochrome P-450 system may function at reduced ca-
pacity for three weeks or longer after vaccination.3 The
ytochrome system is a major pathway for drug
netabolism; hundreds of drugs are metabolized via
his route and an abbreviated list appears in the Table.
Although the influenza vaccine has achieved moder-
tely widespread use in the above-mentioned popul-
ations, many physicians are not aware of the potential
dverse side effects, many with serious consequences
hat can occur in patients vaccinated while being
naintained on medications metabolized via the
ytochrome P-450 system. The following case presen-
ation describes an adverse reaction occurring in a
patient vaccinated while receiving a long-acting
benzodiazepine.
CASE REPORT
An 86-year-old alert and oriented resident of a skilled
nursing facility was administered 0.5 cc of trivalent flu
vaccine. At the time of vaccination, his medications
included digoxin 0.25 mg/po daily, furosemide 40
mg/po daily, ergoloid mesylates (Hydergine") 1 mg/po
t.i.d., and chlorazepate dipotassium (Tranxene") 3.75
mg/po b.i.d. Two days postvaccination, he fell while
ambulating down a corridor. Twelve hours later, a
nurse found him sitting on the floor by his bed and
noted that he was completely disoriented. He was
transferred to a local emergency room where no trau-
matic injuries were noted on clinical examination. A
skull x-ray, SMA6, and CBC were unremarkable. An
ambulance brought him to our skilled nursing facility.
On initial examination his rectal temperature was
99.2°, blood pressure 140/80, and respirations
22/minute and unlabored. Cardiac examination re-
vealed atrial fibrillation. He was lethargic and dis-
oriented to time, place, and person. There were no focal.
‘From the Department of Medical Education Office. Memorial
General Hospital, Union. Correspondence may be addressed
to Dr. Solomon, Memorial General Hospital, Department of
Medical Education Office, 1000 Galloping Hill Road. Union,
NJ 07083.
“From Elizabeth Manor Nursing Home, Elizabeth.
OL. 81— NUMBER 7— JULY 1984
573
neurologic findings. Ambulation was not attempted.
The patient was continued on digoxin 0.25 mg/po
daily and furosemide 40 mg/po daily. He received two
additional doses of chlorazepate dipotassium (3.75
mg) before it was discontinued. Over the next six days,
a dramatic improvement was noted in both his mental
status and level of physical activity with the patient
becoming both continent and ambulatory as he was
prior to the occurrence of this episode.
DISCUSSION
There are many causes of confusion and lethargy in
the frail elderly. The most likely cause in the case we
presented is an elevated serum nordiazepam level.
Chlorazepate dipotassium is decarboxylated in the
stomach to form nordiazepam. its main active
metabolite. Nordiazepam then is hydroxylated via the
cytochrome P-450 system to form either oxazepam or
p-OH nordiazepam, both of which are excreted by the
kidney in the free as well as conjugated glucuronide
form.* 1 2 3 4 5 Unfortunately, we did not obtain a serum nor-
diazepam level to substantiate our hypothesis; how-
ever, based on the sequence of events, we feel the most
likely explanation is the one offered above.
COMMENT
Physicians should be aware of the potential for
adverse drug reactions in patients who receive in-
fluenza vaccine while being maintained on medi-
cations that are metabolized via the cytochrome P-450
TABLE
Abbreviated List of Medications
Metabolized Via Cytochrome P-450 System
Alprazolam
Barbiturates
Chlorazepate dipotassium
Chloridiazepoxide
Diazepam
Digit ox in
Theophylline
Tricyclic anti depressants I
Flurazepam hydrochloric
Meperidine
Meprobamate
Phenothiazines
Phenytoin
Quinidine
Warfarin
system. These medications either should be reduij
in dosage or replaced by medications that bypass *
cytochrome P-450 system. In the case we describl
chlorazepate dipotassium could have been replaced >|
oxazepam while retaining the desired drug effect.
REFERENCES
1. Ouslander JG: Drug therapy in the elderly. Ann /ntji
Med 95: 71 1-722. 1981.
2. Kramer P, McClain CJ: Depression of aminopyrf
metabolism by influenza vaccination. N Engl J JV|
305:1262-1264. 1981.
3. Renton KW, Gray JD, Hall RI: Decreased eliminatiorl
theophylline after influenza vaccination. C'MAJ 123:288-2,
1980.
4. Remmer H: The role of the liver in drug metabolism.
J Med 49:617-629, 1970.
5. Abbott Drugs: Tranxene“ (chlorazepate dipotassiu ;
Drug Monograph.
i
574
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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)L. 81-
NUMBER 7— JULY 1984
575
Medical History:
Conversations in Medicine*
Allen B. Weisse, m.d., Newark**
A visit to the author’s place of training provided stimulation for
a book about the 20th century advances of medicine. Interviews
with 1 6 outstanding physicians , scientists , and teachers ,
constitute the results of a five-year endeavor.
It all began in the spring of 1978 when I was
invited back to the University of Utah Col-
lege of Medicine by my former colleagues to
give several lectures on the cardiovascular research we
had been performing at UMDNJ-New Jersey Medical
School. As I prepared for these presentations, there
gradually dawned upon me the opportunity for
another kind of experience at the institution where I
had received my training in cardiology over a two-year
period beginning in 1961.
Since I left Utah, clinicians and basic scientists who
learned of my experience there asked me about two of
the medical giants who made that institution world
renowned. They were the hematologist and chairman
of the department of medicine. Maxwell M. Wintrobe,
and the pharmacologist, Louis S. Goodman, who put
Utah on the medical map and was instrumental in
establishing pharmacology as a discipline in its own
right through his research and the famous textbook
he coauthored with Alfred Gilman.
Unfortunately, I was hardly in a position to know
what Wintrobe and Goodman were like. Wintrobe
headed the department of medicine of which I was a
member as a cardiology fellow, but most of the junior
physicians in the department were more interested in
maintaining a comfortable distance from Wintrobe
than coming under close scrutiny by him. He was well
known for his withering criticism when performance
did not match up to his exacting standards. Being in
cardiology rather than general medicine or hemj
tology, I kept a low profile vis a vis the chairman fo
the two years I was there. The price I paid was tha!
I scarcely knew him.
My contacts with Goodman were even more remote'
He was the head of a basic science department whil
I was in clinical medicine. My total knowledge of Goodi
man derived from glances at official functions am
admiring reports I received from a Ph.D. candidate ii
pharmacology who rented rooms in the same buildin;
as I.
On the eve of my departure for Utah, I began to lool
forward to the opportunity it would give me to mee
and chat with these great medical figures, as a “visit
ing fireman.” I then would make up for my past defi
eieneies, at least in part. Simultaneously, I was seized
with the thought that many people in and out of medi
cine might like to learn how such major figures, in the
twilight of their careers, looked upon their years o
struggle and accomplishment.
’Adapted from a talk presented to the New Jersey Historica
Society. Conversations in Medicine: The Story of Twentietl\
Century American Medicine in the Words oj Those Wht
Created It was published by New York University in June
1984.
**Dr. Weisse is Professor of Medicine, UMDNJ-New Jersey
Medical School. Correspondence may be addresed to Dr
Weisse, UMDNJ-New Jersey Medical School, 100 Berger
Street, 1-576, Newark, NJ 07103.
576
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
t was not until the early part of this century, es-
j cially in the years preceding and following World War
I that American medical science emerged from being
i nedical backwater in the shadow of European sei-
tce. During those years, Wintrobe, Goodman, and
ners helped usher in the era of American medical
j e-eminence. Who would not be moved by the per-
fe'jnal stories of these leading figures in this develop-
ing? These thoughts stimulated me to write a book,
o nversations in Medicine, in which I attempt to re-
1 e this tale through the recorded recollections of
tese major figures, bridging their individual accounts
|th the medical and social history of the period in
« rich they worked.
iSince we had so many roots in European medicine,
had to include some individuals whose backgrounds
yuld bring this to light. In medicine, I thought of my
Inner mentor at the State University of New York in
l ooklyn, the cardiologist, William Dock. Not only had
trained in Vienna, but he was the son of the first
11-time medical department chairman in the United
: ates, George Dock, a protege of Osier. William Dock
Iso was well grounded in pathology, the foundation
pon which the advances of medicine within this een-
iy initially were based.
In surgery, the University of Minnesota's Owen H.
angensteen, dean of American surgery for so many
ars, was the obvious choice. It was he who did so
uch to bridge the gap between physiology and
inical surgery. He was well acquainted with the
atus of European surgery at that time and had per-
>nal knowledge of all the great American surgeons
om the Mayos and Harvey Cushing and beyond. He
so was a medical historian.
What about the rest? I felt that the choice of eon-
ibutors best could be guided by the major develop
lents of the period: 1) the growing understanding of
ie formation of the blood elements (hematology) and
le importance of nutrition within this scheme; 2) the
dvances in pharmacology: antibiotics for infectious
iseases and useful drugs for the treatment of
ardiovascular disease; 3) the development of heart
argery; 4) the expansion of knowledge about im-
runology and cancer; 5) the beginnings of organ
■ansplantation and artificial organs; and 6) the dis-
bvery of the chemical configuration of DNA and the
irth of molecular biology.
In the first decades of this century, laboratory medi-
ine was brought to the bedside largely by hematolo-
ists. Wintrobe’s accomplishments make this ap-
arent. Preceding this, however, and firing the im-
gination of physicians everywhere was the discovery
f the role of nutrition in the formation of the blood
ells. This was exemplified best by the work of George
L Minot and William Parry Murphy in the liver treat-
lent of pernicious anemia for which they shared a
lobel Prize in Medicine with George H. Whipple of
Rochester in 1934. Dr. Murphy was the last surviving
lember of this triumvirate and although debilitated
y age and illness, he welcomed my visit to his home
n Brookline, Massachusetts.
Goodman’s career touched much of the progress in
harmacology, which included the introduction ol
ntibiotics for the treatment of infectious diseases,
his triumph can be appreciated best through the eyes
of one whose career had spanned the era preceding the
introduction of antibiotics and the years through
which their utilization has flourished. Boston’s legend-
ary Louis Weinstein was the obvious choice here.
For heart surgery, I wanted to turn to someone who
was there at the beginning. The first major attempt to
deal surgically with intrinsic disease of the heart itself
involved the introduction of the closed mitral com-
missurotomy for mitral stenosis. Charles P. Bailey,
Dwight D. Harken, and Sir Russell Brock all shared in
this accomplishment. Bailey, a New Jerseyan, however,
had the slight edge of priority and offered the ad-
ditional advantage of his postsurgieal career. He had
turned to law following surgery and had become an
expert in medical malpractice, one of the most disturb-
ing recent problems to the profession.
The growth of heart surgery demanded an expansion
of our knowledge about cardiovascular physiology in
man, which could be learned only through the develop-
ment of cardiac catheterization techniques. This nat-
urally led to the second Nobel Prize Laureate in the
book, Andre Coumand, who shared this award with
Dickinson Richards and Werner Forssmann in 1956.
More recent general advances in surgery could best
be addressed by Harvard’s Francis D. Moore who head-
ed the surgical department at the Peter Bent Brigham
Hospital for a 30-year period beginning in 1948. His
knowledge of medical manpower problems and the
Boston medical scene were added bonuses.
In order to get an outsider's view of American medi-
cine during this period, I visited Sir George Pickering
at Oxford. Pickering had a very active career as a re-
searcher in hypertension and as an educator. During
the course of his career, he visited almost every major
medical school in America. He was well versed in what
we did well and what he felt we did badly. He also was
an expert on Great Britain’s National Health Service
and had a contrasting view to present on the proper
role of government in medicine compared to that
espoused by his counterpart, Moore.
With a view to more recent developments in Ameri-
can medical science and what they portend for the
future, I turned to Robert A. Good, at 62 the youngest
of those appearing in the book. His personal career in
immunology and cancer research has encompassed
almost every major development in the field over the
last 40 years. Good had an additional element of
interest: his shattering experience at Sloan-Kettering
during the Summerlin mouse-painting episode 10
years ago. This provided an opportunity to discuss
medical ethics and lessons learned about potential
fraud in research.
No single individual has been more involved in (he
development of artificial organs than Willem J. Kolff,
developer of the first practical artificial kidney. He also
has been the force behind the development of the
artificial heart, ventricular assist devices, and artificial
eyes, ears, and limbs.
We now know the future of medicine lies at the level
of the gene in the world of biochemistry. To enlighten
us on the growth of this field through his own ex-
periences and to point the way to the future I turned
to Dr. Arthur Komberg, the final Nobel Prize recipient
in the group who was known for his work in DNA
replication mid other aspects of molecular biology.
OL. 81— NUMBER 7— JULY 1984
577
In addition to the strictly scientific aspects of Ameri-
can medical progress, I wished to reflect the changing
relationship between organized medicine and such
groups as blacks, women, and Jews. Fortunately, I was
able to enlist the cooperation of several individuals
who were prominent scientists and educators despite
the restrictive prejudicial atmosphere of the time.
Joseph L. Johnson served as either dean or head of
the physiology department at Howard University’s
medical school for over 30 years until his retirement
in 1971. Marian Ropes, the first woman medical resi-
dent at the Massachusetts General Hospital, has
achieved wide recognition as an authority in
rheumatologieal disorders, especially lupus eiythema-
tosis. New Jersey's Dr. Lena F. Edwards started her
medical life with three strikes against her: a woman,
a black, and an interest in obstetrics, a specialty whose
members were reluctant to accept women. In addition
to becoming one of the first black women to become
board certified in obstetrics and gynecology, she was
a pioneer in the introduction of community involve-
ment in the delivery of medical care through her lead-
ership in the construction of a migrant workers' ma-
ternity hospital in Hereford, Texas, in 1961.
Who would not be moved by
the stories of leading figures
in the development of
American medical pre-
eminence?
The mechanics of this oral history project may
interest the reader. After gaining the acquiescence of
an individual, I obtained a copy of his or her cur-
riculum vitae and bibliography. Prior to the interview,
I absorbed as much background material as possible
and then contacted the subject’s medical contem-
poraries, friends, and relatives to ferret out the most
fruitful avenues of interrogation. By the time of the
interview, I felt well prepared to get the most out of the
allotted hour or two; in some eases, a second meeting
was arranged.
The taped material was typed, edited, and rearranged
to achieve a coherent and meaningful form before sub-
mitting the polished version to the interviewee for final
approval. It was my assurance that no chance remark
that might prove embarrassing would appear that
achieved the trust and openness vital to every story.
A few items fell by the wayside as a result (one con-
tributor had the endearing but disconcerting suspi-
cion that almost every other paragraph might con-
stitute grounds for libel action) but no essential infor-
mation was sacrificed to discretion. In several in-
stances where I thought this might prove to be the
case, I was able to convince my interviewee about the
importance of the material which wound up in print.
The first interview took place in March 1978 and the
final one in April 1983. At the conclusion of this work,
1 felt confident that the 16 life histories that I had
included would provide a representative panorama of
American medical history during this period, but I also
realized that some personal bias had been inescapable
in the selection process. Colleagues who learned of this
project invariably came up with suggestions for h*
or that individual who, for various reasons, could >
be included. Several areas of progress, endocrinob
and metabolism, were underemphasized because*
the deaths or illnesses of those whom I would hi
approached. Personal reasons also intruded. In «
instance, the person whom I had considered the rrl
outstanding woman physician of this time, worldw ?.
ultimately refused to cooperate despite a year it
pursuit on my part.
Such omissions notwithstanding, I believe the o j
inal purpose of the book was achieved. As the fi t
lines were written, I was tempted to draw some br<:
conclusions from the personal histories I hi
gathered. Although the method of selection undenia,
was idiosyncratic and never would stand up to ai
kind of statistical analysis, there were some obviou;
broad strokes of character and experience here th;;|
felt compelled to acknowledge.
The sample of women obviously was too small to
representative: it is sufficient to note that they all hjlj
to be exceedingly bright, determined, and lucky I
achieve prominence in their selected fields.
Among the men, certain common attributes we
striking. The first requisite for success seemed to
a father who was dead, distant, or indecisive in ten
of providing guidance. Bailey, Pickering, Johnson, a
Good were all deprived of this role model in thi
youths by the untimely deaths of their fathers. In oth * 1
instances, there seemed to be an emotional separate
between father and son. Only Andre Coumand, in t
course of our talk, touched on a paternal influence th1
seemed truly profound. As striking as the absence !
fathers was the presence of strong-willed encouragii j
mothers. Without them, it is doubtful that many of t
men would have persevered as they did.
Poverty also seemed to be a necessary spur for maj i
of these men. It runs like a leitmotif through many |
their stories. Interestingly, this did not serve as j
incentive to become wealthy but provided a rigoroi,
exercise in preparation for the other future hardship !
they would have to face. Racial, religious, and sexu
discrimination are aspects of medicine that are grov
ing less and less prominent in modem American si
eiety but they were an unquestionable part of the pa
as reflected in the experiences of some of those will
whom I spoke.
What about the tradition of medical families? Ui
questionably, there are distinguished families of ph;
sicians from one generation to the next: the Mayos, tf
Warrens in Boston, and others. But, these probably ai
exceptions to the rule. Among those I interviewed on
Dock and Kolff had physicians as fathers (Lena E(
wards’ father was a dentist) and only Dock’s father we!
pre-eminent in his field. I found it comforting to cor
elude from this that in a democratic society outstanc
ing physicians can arise from any background.
Finally, I thought of my own children and wondere
if they would follow in my footsteps or go beyond thenl
As much as we all profess an attitude of support an
encouragement for the career goals of our offspring
whatever their direction, a certain desire to se
another physician in the family always is there. Medi
cine is a wonderful profession. But, after noting th
characteristics of my own selection of medical greats
578
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
joked with some bemusement upon the "disadvan-
>ed” background of my own two teenagers. Both of
?ir parents are alive, well, and members of the medi-
profession. As a result, their economic resources for
h furthering of their education, although not ex-
vagant, are certainly more than adequate for the
;k. They attend a suburban school system that is
;tstanding, especially in its recognition and catering
^gifted children. They live in a social milieu in which
tors of discrimination, which they might have faced
in the past, have been minimized greatly if not totally
obliterated. With all this going against them, I asked
myself, tongue-in-eheek, if any source could provide
them the necessary spur for achievement in medi-
cine— or any other field of endeavor for that matter.
One day they may read this book. Learning about this
extraordinary group of men and women may inspire
them to accomplish whatever is potentially within
their grasp. After all, what more can we ask of our sons
and daughters, our students, and ourselves?
;
it. 81— NUMBER 7 — JULY 1984
579
Sometimes
you just can't
When it comes to saving lives, teamwork
becomes not only desirable; it becomes
necessary.
In an operating room, in an emergency room,
in consultation with other physicians, teamwork
helps you do your job to the best of your ability.
The American Medical Association and your
state and county medical societies believe in the
value of teamwork — and the necessity of it, in
the face of an increasingly complex professional
environment.
We also believe that medical societies have
certain tasks that the individual physician
couldn’t possibly assume — and shouldn’t
have to.
For example, to keep government regulations
from interfering with your practice, we effectively
represent your interests at local and nationa
levels.
To influence policies of organized medicin^
with which you disagree, we provide the mean^
to have your views heard and respected. I
And to keep you up to date on the latest medJ
ical advances, we publish JAMA, AM News,
specialty, state, and county journals.
In fact, for all the times you can’t operate
alone, your medical societies will be there].
Working with you to defend your rights and pro-!
tect your freedoms.
Join Your
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580
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Current Nutrition: Progress in
'ood Allergy and Food Sensitivity*
Richard N. Podell, m.d., new providence**
\Claims about food sensitivity are flawed by their reliance on
anecdotal testimony.2 5 Despite this discouraging history there
has been a revival of serious interest in food sensitivity. Although
the number of controlled studies is too small for firm conclusion ,
several recent reports support the view that food sensitivity may
i be much more important than usually is credited.
More than 2,000 years ago Hip-
pocrates proposed that idiosyn-
cratic reactions to food were a
| ajor cause of illness.1 This and most other claims
bout food sensitivity are flawed by their reliance on
lecdotal testimony.25 Most physicians have been re-
ictant to accept a major role for food sensitivity.67
espite this discouraging history there has been a
Ivival of serious interest in food sensitivity. Although
le number of controlled studies still is too small for
rm conclusion, several recent reports support the
iew that food sensitivity may be much more import-
lit than usually is credited. This paper provides a
elective review and analysis of current research.
May and his colleagues at Denver’s National Jewish
ospital deserve credit for being the first to apply sys-
‘matically modem scientific double-blind research
Methods to the study of food sensitivity. +89 May shad-
'd 38 children with asthma whose parents and phy-
jicians believed that their child’s asthma was made
rorse by the ingestion of specific foods.8 The children
rere hospitalized and fed the suspect foods, or a
lacebo, which were hidden in an opaque capsule,
ositive reactions after feeding the suspect food oc-
urred in only 14 of 38 children and for only 14 of 70
uspect foods. Usually, only gastrointestinal symptoms
esulted and none suffered an acute attack of asthma,
i every case where the food challenge was positive, the
jkin prick test was positive. However, the skin prick
test also was positive in many instances in which
clinical sensitivity could not be confirmed by the feed-
ing challenge.
The following conclusions have been inferred:69
1 . Although food-induced asthma can occur, it prob-
ably is rare since only a few of these carefully selected
patients reacted at all after feeding and clinical asthma
was not induced in any.
2. A positive history of food-induced asthma is un-
reliable and is more likely to be false than true.
3. A negative prick test probably rules out signifi-
cant food sensitivity, but a positive prick test does not
predict reliably that a patient is clinically sensitive.
In short, significant food sensitivity is unlikely even
when the history and skin prick tests are positive. A
*This column is prepared under the direction of Herman
Baker, Ph.D., Professor, Preventive Medicine/Community
Health and Medicine, UMDNJ-New Jersey Medical School.
**From the Department of Family Medicine, UMDNJ-Rutgers
Medical School, Piscataway, where Dr. Podell is Clinical As-
sociate Professor. Correspondence may be addressed to Dr.
Podell at 29 South St., New Providence, NJ 07974. This paper
was presented in the Allergy, Immunology, and Infectious
Diseases Lecture Series, United Hospitals Medical Center,
Newark, December 8, 1983.
+The term sensitivity is preferred when the mechanism of an
idiosyncratic reaction is unclear or when it is unrelated to
an IgE mechanism. The term allergy should be restricted to
instances in which reagenic antibody (usually IgE) is believed
to be important.
OL. 81— NUMBER 7— JULY 1984
581
suspicion of food sensitivity almost always will prove
false if the skin prick test is negative.
This interpretation has been accepted by most
authorities,6'9 but not by all.10 The critical issue is
whether the particular oral food challenge protocol
used by May is, in fact, a valid and sensitive measure
of clinical sensitivity to foods.
Surprisingly, there have been no independent sys-
tematic controlled assessments of the reliability and
validity of May’s oral food challenge protocol or of the
other popular protocols for diagnosing food sensitivi-
ty.2411 Critics of the May protocol argue that it is likely
to underestimate the prevalence of food sensitivity.
May discussed one pertinent issue: that there was
an extremely high prevalence of skin test positivity
among subjects who had a positive history and a
negative food challenge. Although only 10 of 56 cases
with negative food challenge had a positive prick test
to the suspect food, 52 of the 56 had positive skin tests
if the more sensitive intradermal tests were in-
cluded.911 Such a high correlation between history and
skin test results would not be expected if the positive
history were based on a placebo effect.
May interpreted these as instances of “asymp-
tomatic hypersensitvity.” He argued that the subjects
were biologically allergic to the suspect foods, but not
enough for the allergy to be clinically meaningful. How-
ever, these facts also are consistent with another possi-
bility: that the history and skin test results were both
meaningful, but that May’s particular oral food
challenge protocol was not sensitive enough to demon-
strate it.
Several reasons why the May protocol might be a
weak one have been advanced. For example, because
May placed the test foods in small opaque capsules,
challenge meals rarely were larger than one-third of an
ounce. Larger challenges or repeated challenges at con-
secutive meals might have elicited greater clinical reac-
tions.11
According to some authors the duration of
abstinence before challenge may critically affect re-
sults.45 Thus Rinkel argued that clinical sensitivity to
a commonly eaten food often decreased after a month
or so of abstinence.4 Therefore, oral challenges should
be done within a few days to a few weeks after the
suspect food is omitted from the diet. In contrast. May
required his subjects to be off the suspect food at least
two weeks. However, May provided no data on the
actual duration of abstinence before challenge. Since
the parents and physicians of subjects felt strongly
that the test foods triggered asthma, it is not at all
farfetched to imagine that many of the children with
negative oral food challenge had been off their suspect
foods for many weeks or months before the negative
challenge. Although one cannot answer with certainty,
several recent studies suggest that the May protocol
may underestimate the prevalence of clinical food
sensitivity.
ASTHMA
A recent Danish study suggests that dietaty factors
adversely affect a substantial proportion of seriously
ill asthmatics. Hoj et al. studied 41 consecutive hospi-
talized asthmatics, who were allocated double blind to
one of two diets.12 One was a defined elemental formula
diet, thought to be hypoallergenic.13 The other was
normal hospital diet. Both were liquified and swe
ened so as to be similar in appearance and taste. Me*
cal treatment was done in the usual way and outcom
were assessed by a predetermined formula based
pulmonary functions and medication taken during t
last v the first four days of the two-week trial peric
Overall, patients on the elemental diet did subste
tially better than those eating the hospital diet. Ni
of the 21 subjects completing the elemental diet Li
proved according to the preset criteria; none c
teriorated. Only 1 of the 16 hospital diet subjects if!
proved and 5 subjects deteriorated. The difference
outcome scores was statistically significant (1
<.05). The 9 elemental diet patients who improv
substantially had no higher frequency of positive sk
prick tests to common foods than did the 12 patien
whose condition remained stable. The authors co
eluded that a trial of elemental diet is justified for
perennial asthmatics even when there is little eviden
of extrinsic etiology. This study has several limitation
including small numbers of patients and the difficul
in disguising the taste of an elemental diet. Howev<
the major concern is the relatively poor results for tl
control group subjects. This suggests that much
most of the benefit attributed to the elemental formu
diet actually might be an artifact due to the atypical
poor outcome of control group subjects. It is extreme
disappointing that no attempts to replicate this ir !
portant study have yet appeared.
MIGRAINE
It is surprising that migraine, a condition n
thought of as “allergic,” is the focus of a number
reasonably well-designed food sensitivity studies. Tl
most important is a report from the pediatric migrair
clinic at the Hospital for Sick Children in London
Eighty-eight children with severe, at least weekly, rr
graine completed a three- to four-week period in whic
their diet was limited to one meat, one starch, one fru
one vegetable, water, and vitamins. During the last tv
weeks of this elimination diet, 78 subjects had r
headaches, 4 patients were rated as improved, and on
6 patients were not improved. Foods were added bac
one at a time. Each new food was taken in multip
servings for a week or until migraine recurred. Th
continued, apparently for many months, until a sock
ly and nutritionally acceptable diet was achieved.
Among the 82 subjects who improved after tl
elimination diet, 74 subjects relapsed after challengi
to an average of 2.7 foods each. The key question wj
whether these apparent “reactions” were specific <
whether placebo effect or other nonspecific facto
were responsible. Curiously, at the start of the stud
four of the five authors believed that food-associate
migraine was basically a placebo effect. They were su
prised when the data confounded their expectation
Forty subjects were selected for two double-blin
challenges. For one week, each ate a placebo food-
paste of strongly sweet or sour nonsuspect food. Fc
another week they ate a suspect food, which was di:!
guised by blending it into the placebo. Headaches c
related symptoms occurred much more often durin
the week of eating the suspect foods. Thus, 28 subject
reacted only with the suspect food and only 2 subject
582
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
eacted only after the placebo. Four subjects reacted
fter both, and 2 subjects after neither. Thirty-five sub-
lets preferred the placebo and only 2 subjects
ireferred the suspect food. The differences statistically
j-e significant (P<0.001), confirming that most of the
ubjects were specifically sensitive to the foods that
ppeared to provoke their headaches. There appears to
;ie no serious criticism of the study’s essential validity,
lowever, the severity and complicated nature of these
hildren’s illness may make them unrepresentative of
he migraine patients seen in more general practices,
'hese findings are yet to be confirmed independently,
‘lowever, for now, the preferred conclusion must be
jhat there is a population of children with migraine-
ke illness in which food sensitivity plays a critical
,ole.
This study also confirms May’s observation that
ositive skin prick tests often are false positives: 58
ercent of the positive skin-priek tests could not be
onfirmed by oral food challenge. However, eontraiy to
day who found no false negative prick tests, 75 per-
ent of the foods which appeared to provoke migraine
ifter oral challenge gave a negative prick test. This
nplies that food sensitivity in migraine is largely not
JE mediated or that the IgE is not detectable in the
sual ways. For example, the specific IgE might be
jcalized to the gut or might be directed against a
letabolic product of the food rather than at the food
.self. In any case, skin prick testing appears to be of
ttle value in predicting food sensitivity in migraine.
Specific food sensitivity is
likely to prove important in
migraine , eczema , irritable
bowel syndrome , and
asthma .
The most important conclusion may relate to the
alue of different oral food challenge protocols. The
ligraine study challenged large amounts of food re-
eatedly. On the average it took two days for food
aallenges to induce headaches (range: less than one
our to more than seven days). Had May’s protocol for
ral food challenge been applied, it would have failed
|p detect the large majority of instances of clinical
jmsitivity. Even the more vigorous Rinkel challenge
rotocol probably would have been less sensitive than
le heroic protocol used by the London investigators,
his result casts doubt on the validity of the May oral
lallenge protocol as the definitive method for the
iagnosis of food sensitivity. Therefore, it forces the
iopening of all issues which were decided based on
(ay’s methodology.
Several studies suggest that food sensitivity also has
a important role in adult migraine. However, two
udies are flawed by their failure to use double-blind
.‘chnique.1415 One appears to be satisfactorily eon-
oiled.16
Another intriguing experiment recently was re-
sided. It suggests a possible nonimmunologic mech-
aism for food-induced migraine.17 It was found that
atients with a histoiy of diet-induced migraine had
lower platelet levels of an enzyme known as
phenolsulphotransferase-P (PST-P). Both healthy con-
trols and migraine patients whose headaches were not
induced by foods had normal levels. PST-P may have
a role in the detoxification of phenolic compounds,
which are common in foods and in food additives. If
this finding is confirmed and if PST-P levels also are
decreased in the gut and/or other pertinent organs,
then a plausible nonimmunologic mechanism for diet-
induced migraine could be postulated.
ECZEMA
Although dermatologists tend to be dubious, al-
lergists long have argued that eczema contains import-
ant elements suggestive of an allergic condition. High
levels of IgE in serum are common and there is a
substantial association with other allergic diseases
such as asthma and seasonal rhinitis. Recent reports
now provide fair, but not conclusive, evidence that
elimination diets are helpful in treating eczema1820
good evidence that sensitive foods can provoke pruritis
and rashes after oral challenge21 and fair evidence that
sodium cromoglycate, a mast cell stabilizer, is effective
in eczema when taken orally.22 Taken together these
studies suggest an important role for food sensitivity
among some patients with eczema (Two new double-
blind studies also support a link between food allergy
and eczema6364)
IRRITABLE BOWEL SYNDROME
That food allergy and sensitivity can provoke
gastrointestinal symptoms in children or that gluten
sensitivity occurs in children and adults is not in dis-
pute.23 25 Recent evidence that gluten enteropathy is a
multisystem disease also is reasonably well based.26'30
What has been controversial, though, is whether that
most common of all intestinal problems, irritable bowel
syndrome, also results in part from sensitivities to
specific foods.
Two recent double-blind studies support the view
that specific food sensitivity is important in some pa-
tients with irritable bowel syndrome. Alun-Jones et al.
placed 21 subjects with diarrhea and painful type ir-
ritable-bowel syndrome on a modification of the Rinkel
elimination/challenge protocol.31 After one week on a
diet limited to one meat, one fruit, and spring water,
14 of the 21 subjects were clear of symptoms. Open
challenge with individual foods and three subsequent
repeat challenges implicated one or more foods as
specific triggers. The most common were wheat (9 per-
sons), com (5), daily (4), coffee (4), tea (3) and citrus
(2). In all eases of wheat intolerance, small-bowel
biopsies were normal.
Six patients received double-blind challenge of either
suspect foods or a nonsuspect placebo. These were
liquified and fed through a nasogastric tube. Reactions
occurred after the suspect food 10 of 12 times and after
the placebo food only 1 time in 12 (P<0.01). Five ad-
ditional subjects were tested single blind and correctly
identified the test food and the placebo in each of ten
challenges.
Bentley, Pearson, and Rix did a similar study,
although their elimination diet appears not to have
been rigorously enforced.32 Although a high proportion
of subjects improved during the elimination phase.
3L. 81— NUMBER 7^JULY 1984
583
double-blind challenge using the capsule technique
disclosed that only three of eight subjects tested could
repeatedly distinguish test foods from placebo. As
might be expected substantial psychopathology was
demonstrable among these irritable bowel patients.33
However, this was true among both those passing and
those failing the double-blind verification challenge.
Although the two studies differ in the proportion of
subjects who could distinguish suspect foods from
placebo, both document that food sensitivity occurs in
a significant proportion of irritable bowel patients.
Since these studies used different elimination and
challenge techniques, some of the differences in re-
sults may derive from their different testing methods.
These differences emphasize the critical need for vali-
dating an acceptable “gold standard” for the diagnosis
of food sensitivity.
CONCLUSIONS
Although there was little well-controlled scientific
evidence of an important role for food sensitivity before
the 1980s, several respectable studies favoring such a
role have appeared in the last few years. Their number
still is too small for definitive conclusions; however,
they do provide credible support for the view that
specific food sensitivity is likely to prove important in
migraine, eczema irritable bowel syndrome, and
asthma
Claims for an important role for food sensitivity have
also been made for many other conditions, including
rheumatoid arthritis, 3438 hyperactivity in children,3946
thrombophlebitis,47 cutaneous vasculitis,4849 nephrotic
syndrome,50 Sjoegren’s syndrome,51 idiopathic throm-
bocytopenic purpura,5253 cardiac arrhythmia,54
schizophrenia5557 narcolepsy,58 seizure disorder,59
“cerebral allergies,”60 and others.1061 62 However, for the
most part the studies supporting these claims are not
of the same order of quality as the studies reviewed
in this paper. Therefore, even tentative conclusions
would be premature. What is clear is that acceptance
or rejection of these claims will require a commitment
to well-designed research and that is beginning to be
displayed.
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3. Coca A Familial Non-Reagenic Food Allergy. Spring-
field, IL, Charles C. Thomas, 1942.
4. Rinkel H, Randolph T, Zeller M: Food Allergy. Spring-
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5. Randolph T: An Alternative Approach to Allergies. New
York, NY, Lippincott and Crowell, 1979.
6. Golbert T: Food allergy. J Med Soc NJ 77:895-899, 1980.
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8. May C: Objective clinical and laboratory studies of im-
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10. Dickey L: Clinical Ecology. Springfield, IL, Charles C.
Thomas, 1976.
11. Egger J, Wilson J, Carter C, et al.: Is migraine food
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12. Hoj L: A double-blind controlled trial elemental diet
severe perennial asthma Allergy 36:257-262, 1981.
13. Doekhom R Smith T: Use of a chemically defin
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47:204-206, 1981.
14. Monro J, Cami C, Brostoff J: Food allergy in migraii '
Study of dietary exclusion and RAST. Lancet 11:1-4, 19t
15. Grant E: Food allergies and migraine. Lam
1:966-969, 1979.
16. Vaughn TR Mansfield L, Haverly R et al.: The value
cutaneous testing for food allergy in the diagnostic evaluatt
of migraine headache. Ann Allergy 50:362, 1983 (abstrac
17. Littlewood J, Glover V, Sandler M: Platell
phenolsulphotransferase deficiency in dietary migraii
Lancet 983-986, 1982.
18. Atherton D, Soothill J, Sewall M, et al.: A double-blii 1
controlled crossover trial of an antigen-avoidance diet
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19. Hill D, Lynch B: Elemental diet in the management *
severe eczema of childhood. Clin Allergy 12:313-314, 198
20. Juto P, Engling S, Winberg J: Treatment of atop s
dermatitis with a strict elimination diet. Clin Allergy 8:4S I'
1978.
2 1 . Sampson H: Role of immediate food hypersensitivity \
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22. Molkou P, Waguet J: Food allergy and atopic dermatit i
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Allergy 47:173, 1981.
23. Lothe L, et al.: Cow’s milk formula as a case of infantij ;
colic: A double-blind study. Pediatrics 70:7-10, 1982.
24. Kocoshis S, Grybowski J: Use of cromolyn in combinr I
gastrointestinal allergy. JAMA 242: 1169-1173, 1979.
25. Buisseret P: Common manifestations of cow's milk ;j |
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26. Wray D: Gluten-sensitive recurrent apthous stomatiti j
Dig Dis Sci 28:737, 1981.
27. Faizallah R et al.: Adult celiac disease and reeurrei
pericarditis. Dig Dis Sci 27:728-730, 1982.
28. Hallert C, Derefeldt T: Psychic disturbances in adu
celiac disease. Sc and J Gastroenterol 17:17-28, 1982.
29. Katz S, et al.: Dermatitis herpetiformis: The skin ar
the gut. Ann Intern Med 93:857-874, 1980.
30. Doherty M, Barry R Gluten-induced mucosal changt
in subjects without overt small-bowel disease. Lane
517-520, 1981.
31. AlunJones V, Shorthouse M, McLaughlin P, et al.: Focjl
intolerance: A major factor in the pathogeneses of irritabl
bowel syndrome. Lancet 1115-1117, 1982.
32. Bentley S, Pearson D, Rix K: Food hypersensitivity i
irritable-bowel syndrome. Lancet 295-297, 1983.
33. Svedlund J, Ottosson J, Sjodin I, et al.: Controlled stuc
of psychotherapy in irritable-bowel syndrome. Lano i
589-591, 1983.
34. Parke A Hughes G: Rheumatoid arthritis and food: j
case study. Br Med 282:2027-2029, 1981.
35. Hieklin J, MeEwan L, Morgan J: The effect of diet o !
rheumatoid arthritis. Clin Allergy 10:2463-2467, 1980.
36. Kroker G, Stroud R Marshall R Comprehensive er
vironmental control and its effect on rheumatoid arthritf
The American College of Allergists Third International Foo
Allergy Symposium, October 21, 1980.
37. Little C, Stewart A Fennessy M: Platelet serotonin r< |
lease in rheumatoid arthritis: A study in food intolerant p<
tients. Lancet 297-299, 1983.
38. Panush R Carter R Katz P, et al.: Diet therapy fcJ
rheumatoid arthritis. Arthritis Rheum 26:462-471, 1983.
39. Swanson J, Kinsboume M: Food dyes impair per
formance of hyperactive children on a laboratory leamin
test. Science 207:1485-1487, 1980.
40. Mathes J: Effects of artificial food colorings in childre J
with hyperactive symptoms. Arch Gen Psychiatr
38:714-718, 1981.
41. Consensus Conference: Diets and childhood hypei
activity. JAMA 248-290, 1982.
42. Tiyphonas H, Trutes R Food allergy in children witlil
I
584
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
leractivity learning disabilities and minimal brain dys-
ction. Ann Allergy 42:22-26, 1979.
3. Millman M, Campbell M, Wright K, et al.: Allergy and
ning disabilities in children. Ann Allergy 36:149-160,
6.
4. Hughes E, Weinstein R Golt P, et al.: Food sensitivity
attention deficit disorder with hyperactivity (ADD/HA): A
cedure for differential diagnosis. Ann Allergy
>:276-280, 1982.
p. Rapp D: Double-blind confirmation and treatment of
jk sensitivity. Med J Aust 1:571-572, 1978.
6. O'Shea J, Porter S: Double-blind study of children with
terkinetic syndrome treated with multi-allergen extract
lingually. J Learn Dis 14:189-191, 1981.
7. Rea W: Recurrent environmentally triggered throm-
hlebitis. Ann Allergy 147:338-344, 1981.
p. Rea W: Environmentally triggered small vessel
culitis. Ann Allergy 38:245, 1977.
9. Theorell H, Blomback M, Kockum C: Demonstration of
fctivity to airborne and food allergens in cutaneous
culitis by variations in fibrinopeptide A and other coagula-
l, fibrinolysis and complement, parameters. Thromb
iemost 30:598-603, 1976.
10. Sandberg D, Bernstein C, McIntosh R et al.: Severe
-oid-responsive nephrosis associated with hyper-
sitivity. Lancet 388-391, 1977.
1. Cunningham-Rundles C, Randeis W, Safai B, et al.:
fictive IgA deficiency and circulating immune complexes
taining bovine proteins in a child with chronic graft ver-
host disease. Am J Med 67:883-890, 1979.
2. Caffrey E, Sladen G, Isaacs P, et al.: Thrombocytopenia
sed by cow’s milk (letter). Lancet 310, 1981.
3. Whitfield M, Barry G: Cow’s milk allergy in the syn-
drome of thrombocytopenia with absent radius. Arch Dis
Child 51:337, 1976.
54. Rea W: Environmentally triggered cardiac disease. Ann
Allergy 40:243-251, 1978.
55. Dohan F, Grasberger J: Released schizophrenics:
Earlier discharge from the hospital after cereal-free, milk-free
diet. Am J Psychiatry 130:685-688, 1973.
56. Singh M, Kay S: Wheat gluten as a pathogenic factor
in schizophrenia Science 191:401-402, 1976.
57. Potkin S, Weinberger D, Kleinman J: Wheat gluten
challenge in schizophrenic patients. Am J Psychiatry
38:1208-1211, 1981.
58. Bell I, Guilleminault C, Dement W: Hypersomnia mul-
tiple-system symptomatology and selective IgA deficiency.
Biol Psychiatry 13:751-757, 1978.
59. Crayton J, Stone T, Stein G: Epilepsy precipitated by
food sensitivity: Report of a case with double-blind placebo-
controlled assessment. Clin Electroencephalogr 12:192-198,
1981.
60. King D: Can allergic exposure provoke psychological
symptoms? A double -blind test. Biol Psychiatry 16:3-17,
1981.
61. Finn R Cohen H: Food allergy: Fact or fiction. Lancet
426-427, 1978.
62. Gerrard J: Food Allergy: New Perspectives. Springfield,
IL, Charles C. Thomas, 1980.
63. Ratner P, Davis S, Rodriguez M, et al.: The role of food
allergy and dietary manipulation in atopic eczema J Allerg
Clin Immunol 73:175, 1984 (abstract).
64. Sampson H, Jolie P: Changes in plasma histamine con-
centrations following double-blind placebo-controlled food
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73:175, 1984 (abstract).
L. 81— NUMBER 7-JULY 1984
585
JEMPAC Update*
William E. Ryan, m.d„ pennington
The author , as chairman of JEMPAC, presented this speech
at the MSNJ Annual Meeting. Examples of political efforts are
provided to show the influence of JEMPAC.
A generous thank you from JEM-
PAC for your political support
during the past year. Although
we have a long way to go, the past year has been one
of unparalleled success in the political arena
You should know that the PAC movement in this
state garnered $8 1 ,000 in funds and was contributed
to by over 1,300 physicians. Over 600 of you joined
JEMPAC and another 700 physicians sent checks to
MEDAC. The latter fund was instituted this past year
for use in statewide elections.
With that money, we were able to contribute over
$66,000 to the campaign of legislators deemed friendly
to medicine. It is my sincere belief that more as-
semblymen and state senators favorably are disposed
to the cause of medicine, in general, and to the medical
PAC effort, in particular, because of your support.
As you recall, as I addressed you this past year, there
were many threats facing medicine. I spoke specifically
about a physician fee schedule which was introduced
into the language of several bills having to do with
automobile insurance reform. Indeed, this time last
year, it was a strong probability that right now you
would be contending with a state-imposed fee schedule
for the treatment of auto accident victims. This has not
happened, largely because of the new-found influence
and clout which you now enjoy and specifically
through the efforts of our Medical Society lobbyist, Joe
Katz. Mr. Katz, who spoke before you last year, was very
effective in staying the hand of the governor and leg
lators who were in favor of an auto insurance bill w
a fee control board. This is testimony to what politi i
influence really can do.
Perhaps our most dramatic moment came in Ju:
of last year when we were able to thwart the efforts
the optometrists in their effort to practice medicine
treating diseases of the eye. As you know, the <•!
tometrists had a bill introduced which would hr
allowed them to treat diseases of the anterior chamb>
of the eye after receiving a 100-hour instruction cou: '
in pharmacology at Philadelphia College of Optomet
We felt there was more to eye disease than a cou
in pharmacology. The ophthalmologists were incens 1
and we felt that it generally was an incursion into t :
practice of medicine that was not in the patient’s b .
interest. We acted to protect the public, physicians, a|l
ophthalmologists to retain control of medical pract '
in this area However, it was a fight we almost lost. T :
bill came to a vote in the assembly where 41 votes w< :
necessary for passage. Through a combined effort f
multiple parties including the physicians of JEMPA
the ophthalmologists, and the Medical Society of N7
Jersey, particularly again, Joe Katz, the bill fell one vij:
short of approval. It was a victory for us but rest
sured that the same bill, albeit in different languc :
and perhaps watered down, again has been introduc I
into the legislature.
In the fall elections, our political action commit “
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
586
mtributed substantially to the efforts of a number of
gislators and candidates who we felt would support
ledicine. In the state senate. Senator James Bom-
eimer had been a particular thorn in the side of medi-
ne and sat on the veiy influential L.I.P. Committee.
Pe decided to support the candidacy of Peter Garibaldi
ho we felt would be more sympathetic to us. It was
veiy close election but Senator Garibaldi today sits
l Senator Bomheimer’s seat.
These are three examples of the political efforts we
ave had in the state which have come about through
)ur effort in helping us underwrite the political pro-
:ss.
That was the state scene. In Washington, the polit-
os had other landmines for us. Specifically, there was
le issue of mandated assignment under Medicare
hich this year took the form of an attachment to the
mnibus Budget Reconciliation Bill (H.R 5394). The
incipal provisions of the mandatory assignment bill
ere as follows: 1) prevailing charge levels for phy-
cian services provided to hospital inpatients would
;p frozen at the June 30, 1984, level for a year; 2) phy-
cians would be required to accept Medicare assign-
ent for all services provided to hospital inpatients
itil six months after the HHS secretary reported to
ingress on DRG prospective payments for physician
:rvices (due July 1, 1985); 3) as a condition of partici-
ition in the Medicare program, each hospital would
!; required to obtain an agreement from each phy-
cian on its medical staff to accept Medicare assign-
ent for all Medicare inpatient hospital services, and
ilure of a hospital to comply could force the hospital
lit of the Medicare program.
A telegram was received from the AMA a day or so
efore the vote was to be taken. There was very little
me for phone contact with congressional offices but
e did our best.
The Auxilary of the Medical Society, headed by Mrs.
ale Wayman and a JEMPAC board member, Angie
ampo, who were on their legislative visit to Washing-
>n, made a monumental effort to stop this legislation,
hey went to individual congressmen’s offices to argue
lat the legislation was not warranted. It was pointed
it, that there had been no congressional hearings on
le issue. There never have been any data submitted
> substantiate the need for these positions, indeed
hen a physician does not accept assignment, the
nancial obligation for payment is outside the
jirisdiction of the Social Security system. It also was
rgued that physicians were doing their part with the
one-year voluntary freeze and that freedom of choice
of Medicare beneficiaries would be curtailed if patients
found their physicians unable to provide services in
hospitals because their staff privileges had been dis-
continued. Physicians have treated patients who are
indigent or of meager means free or at reduced fees
in substantial numbers over the years. This seems to
be unique to our profession. Have any Medicare
beneficiaries been denied care or taken to small claims
court? Of course not. This is why we feel veiy vigor-
ously that we do not deserve this federal action.
Make no mistake about it, you are asked to conform
to an onerous federal standard as a requisite to pursue
your profession. The government is on the fast track
to control you and your practice. We see this class
action as entirely unacceptable. We feel that your prac-
tice and career are squarely on the line.
We have won a temporary victory. I stress that be-
cause the new legislation, particularly the Kennedy-
Gephardt bill and perhaps some new legislation in-
troduced by Senator Heinz, contain very similar
language to the mandated assignment bill. We will
have a tough fight and the American Medical Associa-
tion, JEMPAC, and the American Political Action Com-
mittee are very cognizant of the antimedical anti-
physician sentiment in Congress.
I called upon the office of Frank Guarini and was told
by his legislative assistant, “You know a lot of the old
folks are for this, don’t you?” The implication was
quite clear that another group of citizens clearly
ranked above us in terms of political clout. I think we
can thank our lucky stars that this legislation did not
get enacted on April 12. What the future holds will
depend upon you.
In conclusion, I wanted to point out that we indeed
have come a long way in terms of political activity and
financial viability. We are an organization “on the roll.”
We have managed to win some battles this year and
to change the political climate to some extent. However,
we have a number of major battles facing us in New
Jersey and nationally.
The JEMPAC board would like your input on the
selection process for candidates we hope to support in
the fall federal election. Please let us know which can-
didates you would like supported and why. It is only
in this manner that we can make an informed judg-
ment.
I thank you for your support in the past and look
forward to your financial and personal input in the
future.
DL. 81— NUMBER 7— JULY 1984
587
FIFTH ANNUAL MEDICOLEGAL SEMINAR
Wednesday, September 12, 1984
8:30 a.m.- 4:00 p.m.
Medical Society of New Jersey Executive Offices
Two Princess Road
Lawrenceville, NJ 08648
presented by
Medical Inter-Insurance
Exchange of New Jersey
Department of Risk Management
Afternoon Session
12:00 Lunch
12:45 “Medical Malpractice; The
View from the Chair”
James S. Todd, M.D.
Chairman, Board of MIIENJ
1:00 “The Professional Liability
World Today; The State of
the Industry”
Peter Sweetland, President,
MIIENJ
1:45 “The Claim Climate in New
Jersey; A History and a
Look at the Future”
Joseph DeRoma, Vice-President,
Claims, MIIENJ
2:30 “An Ounce of Prevention;
Causes of Suits and Programs
Developed To Avoid Them”
Adam P. Wilczek, Director,
Department of Risk Management,
MIIENJ
3:15 Questions and Answers
DETACH AND MAIL TO MSNJ, TWO PRINCESS ROAD, LAWRENCEVILLE, NJ 08648
Enclosed is my check for payable to MSNJ
NAME (PLEASE PRINT)
ADDRESS
|
PHONE #
I
Y
A CONFIRMATION WILL BE SENT TO YOU ALONG WITH DIRECTIONS TO MSNJ.
APPROVED FOR 5% CME CATEGORY I CREDITS
REGISTRATION
PLEASE RESPOND NO LATER THAN AUGUST 31, 1984
NO REFUNDS AFTER SEPTEMBER 10, 1984
MSNJ MEMBER OR MIIENJ INSURED $10.00
NON MSNJ MEMBER OR 25.00
NOT INSURED WITH MIIENJ
Medical Society of New Jersey
Department of Professional
Liability Control
Morning Session
8:30 Registration and Coffee
9:00 Greetings
Frank Y. Watson, M.D., President,
MSNJ and James S. Todd, M.D.,
Chairman of the Board, MIIENJ
9:20 Opening Remarks
James E. George, M.D., J.D.,
Director, Department of Professional
Liability Control
9:45 “The Snitch Bills; Their Impact
on Medical Malpractice”
Vincent A. Maressa,
Executive Director, MSNJ
10:15 “Reporting of Medical Malpractice To
State Board of Medical Examiners”
Joseph A. Riggs, M.D., Member of State
Board of Medical Examiners
10:45 “The New Case Management and
Procedures of Malpractice Litigation”
Honorable Peter Ciolino, Assignment Judge
Superior Court, Passaic County
11:15 Questions and Answers
588
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE;
)OCTORS*
fOTEBOOK
'rustees’ Minutes
lay 2, 1984
A regular meeting of the Board of
rustees was held on May 2, 1984,
it Resorts International Hotel and
asino, Atlantic City. Detailed
linutes are on file with the sec-
tary of your county society. A sum-
lary of significant actions follows:
|
Resolutions of Endorsement . . .
pproved for presentation at the
984 Annual Meeting, resolutions
indorsing the candidacy of Arthur
lemstein, M.D., for election to the
iMA Council on Scientific Affairs
nd Karl T. Franzoni, M.D., for elec-
ion to the AMA Council on Medical
jiervice.
leport of the Executive Director
1) MSNJ Paid Membership . . .
loted that 6,905 members paid
heir 1984 dues as of April 26, 1984.
2) MSNJ Pension Plan . . . Ap-
proved the following two reeommen-
ilations:
That the Horizon Trust Company be
appointed to conduct trustee and
ustodial services for the Medical Society
if New Jersey Employees' Pension Plan.
/OL. 81— NUMBER 7— JULY 1984
That Jamison, Eaton, and Wood be ap-
pointed investment managers of the
Medical Society of New Jersey Employees’
Pension Plan.
(3) TEFRA — ERISA Compliance
. . . Approved the following amended
resolution (italics indicate amend-
ment):
That the Committee on Retirement
Plan for Physicians review the proposal
of Health Care Group and be authorized
to permit its offering as an endorsed pro-
gram of the Medical Society of New Jer-
sey. Included in the evaluation should
be any other plans the Committee feels
it is necessary to review.
(4) MSNJ Employee Pension Plan
. . . Approved the following amend-
ment #6 to the Medical Society of
New Jersey Pension Plan . . .
(a) Change definition of compensa-
tion to conform to statute.
(b) Temporary restrictions on benefits
regarding lump sum payments to the 25
highest paid employees if the Plan has
been amended in the last ten years to
improve benefits.
(e) Compliance with top heavy rules
even though not applicable to MSNJ Plan
as such.
( 5 ) Summer Student Research Fel-
lowship Program . . . Authorized
appropriation of $1,000 for the
Summer Student Research Fellow-
ship Program.
(6) State Board of Medical Exam-
iners . . .
(a) Proposed Rule on Chiropractic
. . . Noted that proposed rule,
N.JAC. 13:35-7.1, concerning chiro-
practic practice, will be considered
at the May 9, 1984, meeting of
SBME.
(b) Greco Case . . . Noted a de-
cision is expected 21 to 28 days after
the case was argued on April 30.
Medical Society of New Jersey Stu-
dent Association . . . Received as in-
formative, with commendation, the
report of the MSNJ Student Associa-
tion.
Council on Legislation . . . Ap-
proved the recommendation stating
the Board approves the positions on
bills of medical importance as rec-
ommended by the Council.
New Business . . .
Physician Supervision of Limited
Licensed Practitioners . . . Ap-
proved the suggestion that MSNJ
sponsor a program for hospital
medical staffs on credentialing lim-
ited licensed practitioners in hospi-
tals.
Retiring Members of the Board . . .
Expressed appreciation to the fol-
lowing retiring Board members for
their dedicated service: Drs. Campo,
Crosby, Greifinger, Ramundo, and
Slobodien.
Trustees* Minutes
May 6, 1984
A reorganization meeting of the
Board of Trustees was held on May
6, 1984, at Resorts International
Hotel and Casino, Atlantic City. De-
tailed minutes are on file with the
secretary of your county society. A
summary of significant actions fol-
lows:
Reorganization . . .
(1) New Members . . . Welcomed
the following newly elected members
of the Board of Trustees: Drs.
Bernard Robins, Carl Restivo, Jr.,
Gerald H. Rozan, Michael M. Heeg,
and Louis L. Keeler.
(2) Chairman of Board of Trustees
. . . Noted that by reason of the
amendment to the Bylaws adopted
by the 1984 House of Delegates, Dr.
Watson will serve as chairman of the
Board of Trustees.
(3) Meeting Schedule . . . Voted to
continue meeting on the third Sun-
day of each month at MSNJ head-
quarters in Lawrenceville.
Standing Committee on Finance
and Budget . . . Appointed Drs.
Carnes, Costabile, and Schauer to
three-year terms on the Standing
Committee on Finance and Budget.
New Business . . .
(1) Annual Meeting Attendance
. . . Noted that an attempt should be
made to discover the reason for de-
clining attendance at the Annual
Meeting.
(2) NJ State Medical Underwriters,
Inc. . . .
(a) Report on Activities . . . Re-
ceived a report of activities by James
S. Todd, M.D., as well as the Annual
Report of MIIENJ and a special re-
port of NJ State Medical Under-
writers, Inc.
589
(b) Board of Directors Appoint-
ments . . . Approved the reappoint-
ment of Dr. Paul J. Kreutz to a three-
year term and noted Dr. Watson des-
ignated Dr. Slobodien to serve as his
appointee.
(3) Referrals from 1984 House of
Delegates . . .
(a) Resolution #1 1 — Quality of
Care Audit of Services . . . Directed
that a communication be sent, in-
forming the Commissioner of Health
that MSNJ still is interested in
having a proper study conducted on
the quality of care audit of services
under the DRG program and to see
if adequate funds are available to
complete the study.
(b) Resolution #28E— JCAH Medi-
cal Staff Standards . . . Referred
Resolution #28E (1984 JCAH medi-
cal staff standards) to Dr. A. Ralph
Kristeller, chairman of the NJ
Chapter of the Hospital Medical
Staff Section, for presentation to the
AMA Section.
(c) Resolution #3— Premium Dis-
count, Professional Liability In-
surance . . . Referred the following
to the Risk Prevention Committee of
MIIENJ with a request for a report
on premium discounts:
Resolved, that the Medical Society of
New Jersey, in conjunction with the
Medical Inter-Insurance Exchange of
New Jersey and other commercial car-
riers, be urged to prepare and present
appropriate seminars on basic medical-
legal matters; and be it further
Resolved, that consideration be given
by the Medical Inter-Insurance Exchange
of New Jersey and other commercial car-
riers to provide a discount of premium
costs for members of the Medical Society
of New Jersey who successfully complete
the seminar, provided it can be demon-
strated that such educational programs
decrease liability claims against the in-
sured.
(d) Resolution #9 — Prevention of
Windfall Profits . . . Referred the fol-
lowing to the Council on Medical
Services and the Committee on
Medical Defense and Insurance for
consideration:
Resolved, that the Medical Society of
New Jersey seek the passage of legis-
lation that requires carriers that pay a
lower fee, when a nonparticipating phy-
sician renders a service, to pay a
premium rebate or dividend to the in-
sured patient.
(e) Resolution # 16 — Opposition to
Mandatory Assignment under
Medicare . . . Referred the following
to the AMA Delegation for introduc-
tion at the 1984 AMA Annual Meet-
ing:
Resolved, that the Medical Society of
New Jersey request that the American
Medical Association continue to oppose
vigorously any attempt by Congress to
direct in any fashion mandatory assign-
ment under Medicare.
(f) Resolution #24 — Mandatory
Assignment . . . Referred the follow-
ing to the AMA Delegation for in-
troduction at the 1 984 AMA Annual
Meeting:
the expense of the private practitioir
through the use of taxpayer funds )
prepare and mail this prejudiq
advertising: and be it further
Resolved, that the Medical Society!
New Jersey present a resolution at J
next AMA House of Delegates, r-j
ommending concurrent action by ■
AMA
(i) Resolution #29E— NJ Stf
Board of Medical Examiners Pi
nouncement of Death Regulati
. . . Referred the following to the E |
ecutive Committee for discussi
with appropriate members of t !
SBME:
Resolved, that the Medical Society of
New Jersey urge the American Medical
Association to research the constitu-
tionality of mandatory assignment being
proposed by Congress or any other
proposal to force physicians to accept
prestipulated fees.
(g) Resolution # 15— Patient Edu-
cation Program . . . Referred the fol-
lowing to the Council on Public Re-
lations for study and a report, and
to the Committee on Finance and
Budget for study:
Resolved, that the Medical Society of
New Jersey conduct a “patient educa-
tion” program, designed to inform the
general public regarding the under-
publicized factors involved in health care
costs and the threat posed to the quality
and availability of said care; and be it
further
Resolved, that an assessment of $100
be levied upon each member in order to
fund this proposal.
Also, requested the Council on Pub-
lic Relations to obtain at least two
proposals from public relations
firms to study the most effective way
to reach the public and the cost
thereof. In addition, noted that a re-
evaluation of the budget should be
made to determine whether an in-
creased allowance is needed for pub-
lic relations.
(h) Resolution #26 — Advertising
on Behalf of HMOs by Department
of Health and Human Services
(HHS) . . . Directed that a letter be
sent to Department of HHS regard-
ing HMO advertising and that the
following be referred to the AMA Del-
egation:
Resolved, that the Medical Society of
New Jersey protest to the United States
Department of Health and Human Ser-
vices that they cease and desist from
using such tactics to promote the growth
of health maintenance organizations at
Resolved, that the Medical Society
New Jersey take immediate steps to
quest changes in the regulation to
move the requirement that the patien
attending physician make the p
nouncement of death. This service can
provided more efficiently by the erm
gency room doctor at the nearest hosj
tal or the county medical examiner; a
be it further
Resolved, that the Medical Society
New Jersey take steps to change the reg
lation to state that the county medic
examiner may call the attending pi
sician and ask him to make the pi
nouncement but that it is not a requii
ment that he do so.
(4) Resolution #19— Mammogr
phy . . . Voted to pospone action c
the following until the 1985 Annu;
Meeting:
Resolved, that the Medical Society
New Jersey adopt and endorse the guid
lines advocated by the American Collej
of Radiology and others as follows:
Women between the ages of 35 and < 1
years of age should have a baseline mar
mogram; b) Between ages 40 and 50, fr;
quency of mammography should 1
every two years. Clinical or risk facto
evaluated by the patient's physician m; i
alter this frequency; and c) After age 5
yearly mammography is recommended
and be it further
Resolved, that mammograms followir
from these recommendations should 1
made with equipment designed for th
procedure.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
Our UMDNJ faculty members re
cently have been granted twi
patents that promise to improv
health care for the people of New Jer
sey and the world.
David M. Goldenberg, Sc.D., presi
dent of UMDNJ’s Center for Mo
lecular Medicine and Immunol
590
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSF
17 (CMMI), has been granted a
i ;ent for a detailed method of de-
iting and localizing tumors. The
i;ent is assigned to Immuno-
! dies, Inc., the private corporation
i ich Dr. Goldenberg heads.
V research team headed by Ralph
Greco, M.D., professor of surgery
d chief of general surgery at
IDNJ-Rutgers Medical School,
ip been granted a patent for the
>cess of bonding antibiotics to
lificial implants. Also, the Food
(d Drug Administration has ap-
)ved the process for additional
-gical procedures.
,f the antibiotic bonding process
:ented by the UMDNJ team works
iliwell with humans as it has with
oratory animals, its application
ild save lives now lost because of
ections that often develop after
plant surgeiy.
fhe FDA which in 1983 granted
•mission for the bonding process
ibe used in vascular implants, has
ended experimental permission
hyperalimentation catheters, ap-
)ved in 1984. Approval for peri to-
il dialysis is pending,
n hyperalimentation, a plastic
heter is placed in a large vein
ough which a patient is fed in-
Ivenously, a procedure widely used
malnourished patients before and
ier major surgery. The UMDNJ re-
jirchers anticipate that an anti-
j)tic bonded catheter will be more
istant to infections and thus de-
base the incidence of complica-
ns and increase utilization of the
icedure.
3eritoneal dialysis involves im-
inting a tube in the abdominal
dty. In cases of kidney failure, it
rinits continuous ambulatory
ansing of body wastes and re-
ices the patient’s dependence on
b machine. Infection of the
jtheter, the most common corn-
cation, requires the catheter to be
noved and dialysis to cease. If the
tibiotic bonded catheters succeed
preventing infection, they will
ve a major impact on the use of
is technique.
pr. Goldenberg, who is based on
s Newark campus, has also re-
ived three previous patents, and
s two patent applications pend-
g. All relate to cancer detection
d therapy. Cancer radioimmuno-
tection, which combines advances
immunology and nuclear medi-
ae imaging, detects cancers in the
!>L. 81— NUMBER 7^JULY 1984
human body by injecting radioactive
antibodies made against cancer-as-
sociated substances. These same
antibodies also can cany other
radioisotopes, drugs, and other
agents to combat cancer cells, thus
offering hope of more effective ther-
apy as well as diagnosis.
CMMI, which was established on
the Newark campus in September
1983, held its formal opening and
dedication on June 13. The center
has initial three-year funding of
more than $3 million, most of it
from the National Cancer Institute.
The CMMI research and therapy
efforts and goals are allied closely to
the new Cancer Research and Treat-
ment Center (CRTC), also on the
Newark campus. The CMMI staff in-
teracts with the faculty members of
the New Jersey Medical School on
the staff of the CRTC.
A “definitive study” on the
feasibility of relocating United Hos-
pitals Medical Center to the Newark
campus has been commissioned by
the boards of both institutions.
APM Inc., New York City-based
planning consultants, will assess
the benefits and risks of the
proposed “colocation” project, as
well as the financial and legal im-
plications, before offering a com-
prehensive package of recommenda-
tions. The task before the consult-
ants is to elaborate on and refine a
preliminaiy feasibility study, per-
formed in 1982.
A final report is anticipated this
fall, in time for a formal colocation
proposal to be submitted for state
review and approval as part of an
Essex County-wide package of
proposed hospital renovation and
expansion projects.
In addition to the project’s poten-
tial for cost efficiencies, colocation
holds other immeasurably exciting
prospects. Joined together, the two
medical facilities would comprise a
new health care complex rivaling
any of the nation’s academic medi-
cal centers and, more importantly,
provide the impetus for a major re-
vitalization of Newark.
In a unique research project at the
Piscataway campus, recovered com-
pulsive gamblers and nongamblers
are being tested in separate situ-
ations to determine whether there
are biological factors which pre-
dispose some people to become com-
pulsive gamblers, or whether the
problem is strictly psychosocial.
The project, funded by a renewable
$75,000 grant from the New Jersey
Lottery Commission, has been set
up by Peter L. Carlton, Ph.D., pro-
fessor of psyehiatiy at UMDNJ-
Rutgers Medical School, in col-
laboration with Drs. Leonide Gold-
stein, Paul Manowitz, and Marshall
Swartzburg, also of the Department
of Psychiatry.
The first step in the three-part
program of research involves testing
complusive gamblers doing “or-
ganizational” tasks while their
brainwaves are recorded on an
encephalogram, or EEG.
The second and third parts of the
study involve testing nongamblers
to determine the characteristics of
their brain organization and to
study biochemical changes when
they are gambling with real money.
Dr. Carlton believes that some
means of biological treatment can be
found to help compulsive gamblers
“kick” their habit, and that studies
of the compulsive gambler may open
up avenues for understanding of
other deviant behavior.
Federal researchers under leader-
ship of NIH investigator Dr. Robert
Gallo, who said they had uncovered
the probable cause of acquired im-
munodeficiency syndrome (AIDS),
credited the UMDNJ-New Jersey
Medical School with helping to
provide the clinical case study and
laboratory specimens which got
them on track to that discovery.
James M. Oleske, M.D., associate
professor of immunology, said that
a key part of the medical school’s
contribution consisted of tissue and
blood samples from children who
are being treated for AIDS which
were sent to researchers at the Na-
tional Institutes of Health. Dr.
Oleske was the first in the country
to present findings that the disease
can be transmitted to children.
Practical Solutions to
Common Transfusion
Problems
H.L. Taylor, m.d.*
Brief guidelines for indications of
blood components are available from
*Dr. Taylor is Medical Director of the
North Jersey Blood Center. East Orange.
591
health care transfusion services.
These are provided as package in-
serts by the blood component
provider (Circular of Information for
the Use of Human Blood and Blood
Components) and are required to be
distributed by federal edict.
Although between 80 and 90 per-
cent of all blood products transfused
either are components or com-
mercial derivatives, guidelines ad-
dressing the more common clinical
problems associated with trans-
fusion are sparse and are scattered
in the literature. This guide will
summarize the more common
clinical problems associated with
component transfusion and offer
practical measures to alleviate these
difficulties.
RED BLOOD CELL COMPONENTS
One of the most common com-
plaints with transfusion therapy is
the slow rate of flow most often as-
sociated with packed red blood cells.
Whole blood collected in CPD-A1 is
converted to red cell components.
The resulting hematocrit ap-
proaches 80 percent. This signifi-
cantly increases the viscosity of the
red cells and contributes to slow flow
rates when red cell components are
transfused. A number of other medi-
cal devices that are used when these
components are transfused also may
contribute to the problem and im-
pede flow.
1. Red blood cell components, un-
like whole blood, appear homoge-
neous even though 20 percent or
more of the content of these units
are fluid and have a higher specific
gravity than plasma or normal
saline. The cellular elements in these
units are denser and will be in high
concentration at the most depen-
dent part of the unit. When red cells
are being transfused, the most de-
pendent part of the transfusion bag
is the point at which the outlet ports
are located. Unless the unit is mixed
thoroughly before and during trans-
fusion, the red cells will collect
around the outlet port, resulting in
increased viscosity around this aji
and this will decrease the flow r;a
2. All blood components shoe
be transfused through filters to pj,
vent aggregates and particulate n t
ter from being infused into the i
tient. Standard blood filters hav;
pore size of approximately 170 i
crons. In microaggregate filters, i
pore size may vary from 10 to 0
microns. Both cause resistance c
flow. Microaggregate filters ca .<
more resistance than stand d
filters and should be used only wl n
medically indicated. The pores if
both standard and microaggrege
filters will become clogged after s'a
eral units have been transfused, ei
this will impede further the f|j|
rate. These filters should be chary®
frequently, particularly in emerge
circumstances and when a pati i
requires massive transfusion.
3. In massive transfusion,
change transfusion, and some ot r
clinical circumstances, in-line bid
warming devices frequently e
used. These increase the surf?
area over which red cell eompone s
flow and, therefore, add resistar \
Their use should be avoided wli
not indicated.
4. Good vascular access witl a
large gauge needle is essentials
rapid transfusion of red cell com -
nents. If either is neglected, -
cep table transfusion rates cannot e
achieved.
5. The use of “Y” sets when tra i-
fusing red cells has numerous I-
vantages. It allows in-line tra;-
fusion devices to be primed r
purged of air or compatible infus i
products. Vascular access can e
maintained between the time till
components are being administer 1.
Also, the appropriate intravenrs
solution can be added to and mf d
with a unit of red cells in orders
decrease viscosity and improve flip*
The only pharmacological cc -
patible intravenous solution -
propriate for transfusion or mix g
with any blood component is non il
saline (0.9 percent NaCl in H1,
U.S.P.). Ringer’s solutions will cai “
clot formation. No drugs should e r
be administered with a blood cc -
ponent through a transfusion s
6. In some circumstances pi -
sure cuff devices are necessary r
rapid transfusion. Hemolysis of 3
cells may occur if extreme pressi ?
is used to force red cells which hip
been mixed inadequately throe i
The Journal of
The Medical Society
of New Jersey
presents
“300 YEARS OF
MEDICINE IN NEW JERSEY”
TMs special issue will be
available in September 1984
1
592
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER^
Iters of small pore size or which
Dntain particulate matter. This
azard also can occur when red cells
re transfused through partially ob-
truded intravenous lines or
irough small gauge needles.
LATELET CONCENTRATES
Platelet transfusions usually are
ot effective in patients who have
apid platelet destruction. These
onditions include idiopathic
arombocytopenic purpura (ITP)
nd untreated disseminated in-
ravascular coagulopathy (DIC). Pa-
rents with thrombocytopenia due to
epsis or hypersplenism also may
ail to benefit from platelet trans-
isions, as may patients with func-
onal platelet disorders such as
aose caused by uremia or drugs. In
aese patients the underlying cause
f the platelet disorder should be
seated if beneficial effects of platelet
-ansfusion are to be realized.
Platelet concentrates must be ad-
ministered through a filter.
Jthough some reports indicate that
latelets may be transfused through
microaggregate filters, it is rec-
mmended that pooled platelet con-
entrates be infused through special
dministration sets within six
ours.
In massively bleeding patients,
latelet transfusion is most effective
I
a achieving hemostasis if it takes
lace after the source of bleeding is
rst controlled by surgical or mech-
nical means.
EUKOCYTE CONCENTRATES
Leukocytes collected by pheresis
f single donors contain 1.0 x 10 10
ranulocytes, variable amounts of
maphocytes, platelets, and red blood
ells. The presence of large quan-
ities of platelets frequently is
lieneficial as many neutropenic pa-
tents also are thrombocytopenic,
his component should be trans-
rsed as soon as possible and only
standard blood filter should be
itsed.
Indications for transfusion vary
rom institution to institution but
isually include the following:
myeloid aplasia, neutropenia (<500
’MN/jul), and fever unresponsive to
n appropriate antibiotic trial for 24
o 48 hours. Because of the short
lalf-life of granulocytes and the dif-
iculties inherent in preparation,
ise of this component should be an-
ticipated as much as possible and
the transfusion service should be
notified in advance when this trans-
fusion may be required.
Chills, fever, and allergic reactions
frequently occur when leukocyte
components are transfused. Use of
antihistamines, steroids, and
nonaspirin antipyretics in premed-
icating the recipient may prevent or
ameliorate these reactions. Severe
febrile and pulmonaiy reactions to
leukocyte concentrate transfusion
may preclude their use in some pa-
tients.
SINGLE-DONOR PLASMA
(FRESH FROZEN)
Fresh frozen plasma (FFP) is one
of the most abused of all blood com-
ponents. It should not be used to
provide blood volume expansion. Os-
motically balanced blood derivatives,
crystalloid, or colloid, are more ap-
propriate in these circumstances.
Similarly, FFP should not be used as
a hyperalimentation substitute in
the nutritionally deficient patient.
Fresh frozen plasma is indicated for
bleeding patients with multiple
coagulation factor deficiencies sec-
ondary to liver disease, massive
blood replacement, and DIC. Since
therapeutic levels of procoagulants
are approximately 30 percent of nor-
mal values, there is no rationale to
replace plasma loss on a unit-for-
unit basis.
FFP also is used for patients with
hereditary factor deficiencies for
which there is no coagulation con-
centrate available, i.e. factor V or XI
deficiencies. It also may be useful for
patients with mild hereditary and
acquired factor deficiencies. The pa-
tient’s ability to tolerate the infusion
volume of plasma without develop-
ing fluid overload must be con-
sidered.
FFP should be administered
through a filter within 6 hours of
thawing. Some published guidelines
allow transfusion of FFP within 24
hours of thawing, but both state and
federal regulations require trans-
fusion within 6 hours.
CRYOPRECIPITATE
Cryoprecipitate consists of the
cold insoluble portion of fresh frozen
plasma and contains concentrates
of factor VIII, Von Willebrand’s fac-
tor, factor XIII, and fibronectin.
Cryoprecipitate can be used to treat
some patients with hemophilia A,
Von Willebrand’s disease, hypofi-
brinogenemia and factor XIII defi-
ciencies.
A recently recognized protein in
cryoprecipitate is opsonic glycopro-
tein (fibronectin) which may be
beneficial in reticuloendothelial
clearance of foreign particles and
promotes wound healing.
Some blood component providers
prepare these components “dry”
with no supemate in a unit to re-
suspend the cryoglobulins in solu-
tion for effective transfusion. When
this method of preparation is used,
a small quantity of normal saline
must be added to the unit to dissolve
this component. When this compo-
nent is prepared by a “wet” method,
i.e. leaving 15 to 20 cc of super-
natant plasma in the unit to facili-
tate resuspension, these difficulties
are infrequent.
Whether this component is ad-
ministered as multiple single units
or is pooled into one container, a
standard blood filter or a filter nee-
dle must be used during trans-
fusion. In either case the component
bags should be rinsed with a small
volume of saline to assure optimal
recovery of the cryoprecipitate con-
stituents. After thawing, this compo-
nent must be transfused within six
hours and appropriate post-trans-
fusion clinical assays (factor VIII,
fribrinogen, PT, and PTT) should be
monitored to assess the effective-
ness of treatment.
AVAILABILITY OF BLOOD
COMPONENTS
Blood and its components fre-
quently are in short supply. Since
only about 3 percent of the eligible
population voluntarily donates
blood, it becomes the responsibility
of the blood centers to produce com-
ponents from each donation so that
it may serve the needs of as many
patients as possible. It also is the
responsibility of each transfusion
service to utilize these blood compo-
nents as effectively as possible.
The concept of the “universal red
cell donor" (Group O, Rh°(D)
negative) and the "universal plasma
donor" (Group AB, Rh°(D) negative)
had its origins in the combat ex-
perience of World War II. This con-
cept remains a legitimate protocol in
urgent, life-threatening clinical cir-
cumstances, but it has become dis-
torted to include nonurgent and
OL. 81— NUMBER 7 — JULY 1984
593
routine transfusion practices. This
unfortunate policy severely com-
promises blood utilization and avail-
ability. The group O patient cannot
receive any other type of red cell
component. The group AB patient
cannot receive any other type of
plasma component. If group O red
cell components or group AB plasma
components are used indiscrim-
inately as “universal types” in rou-
tine circumstances, patients of
these types requiring component
therapy may not have them available
for transfusion. The “universal red
cell and plasma donor” types are not
"universal red cell and plasma re-
cipients.” Type specific red cells and
plasma components should be
transfused whenever possible.
Availability of blood components
can be improved markedly by in-
stituting Maximal Surgical Blood
Order Schedules (MSBOS) and/or
Type and Screen (T&S) Protocols
that are appropriate in individual
health care facilities. Guidelines for
instituting these procedures can be
found in the references.
An active transfusion committee,
which includes peer review from
many medical disciplines, also can
curtail wasteful transfusion prac-
tices.
SELECTED REFERENCES
1. American Association of Blood
Banks: Circular of Information for the
Use of Human Blood and Blood Compo-
nents. American Red Cross, Washington,
1981.
2. D'Aguillo A et al.: Guidelines for the
administration of blood and blood prod-
ucts. J Med Soc NJ 80:437-443, 1983.
3. Freidman BA: The maximum
surgical blood order schedule, in Polesky
HG, Walker RH (eds). Safely in Trans-
fusion Practices. CAP, Aspen Conference,
1980.
4. Greenwalt TJ, et al.: General Prin-
ciples of Blood Transfusion. Chicago, IL,
AMA, 1980.
5. Henry JB: Type and screen, in
Polesky HF, Walker RH (eds), Safety in
Transfusion Practices. CAP, Aspen Con-
ference, 1980.
6. Mollison PL: Blood Transfusion in
Clinical Medicine. Seventh Edition. Ox-
ford, Blackwell Scientific Publications,
1983.
7. Pittiglio DH: Modem Blood Bank-
ing and Transfusion Practices. Philadel-
phia, PA FA Davis, 1983.
8. Snyder EL: Blood Transfusion
Therapy: A Physician's Handbook. Ar-
lington, VA American Association of
Blood Banks, 1983.
9. Wallas CH, MuUer VH: The Hospital
Transfusion Committee. Arlington, VA
American Association of Blood Banks,
1982.
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ALCOHOLISM— George W. Miller, Jr.,
M.D., 77 Grove St., Apt. 8, Montclair, NJ
07042. UMDNJ 1980. Available.
ALLERGY/IMMUNOLOGY— Leonard
Bielory, M.D., 688 Concerto La., Silver
Spring, MD 20901. UMDNJ 1980.
Board eligible. Solo preferred, but flex-
ible. Available March 1985.
T.M. Bokhari, M.D., 48 Anderson Pkwy.,
Cedar Grove, NJ 07009. FJMC. Also in-
fectious diseases (pediatric). Board
certified (PED). Group, partnership,
solo. Available.
ANESTHESIOLOGY— Cau Pham, M.D.,
856 Nelson, Apt. 206, Chicago, IL
60657. Saigon (South Vietnam) 1974.
Group or partnership. Available.
RS. Saraiya, M.D., 88-25A 153rd St.,
Apt. 4-F, Jamaica, NY 11432. Baroda
(India) 1978. Group or partnership.
Available August 1984.
FAMILY MEDICINE— Laurence
Levenberg, M.D., 63 Harrowgate Dr.,
Cheny HiU, NJ 08003. SUNY-Upstate
1966. Group, partnership, solo. Avail-
able.
GASTROENTEROLOGY— Harry D.
Burack M.D., 5548 Waterman PL, St.
Louis, MO 63112. Albany 1978. Also
internal medicine. Board certified.
Partnership, group, solo. Available.
Prakash V. Huded, M.D., 80-15 41 Ave.,
Apt. 606, Elmhurst, NY 11373.
Kamatak (India) 1970. Board certified.
Solo, group, partnership. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, internal medicine. Part-
nership, group, full-time hospital.
Available.
Neil Tarkin, M.D., 6700 192nd St.,
Fresh Meadows, NY 11365. New York
Medical 1978. Also, internal medicine.
Board certified (IM). Any type practice.
Available.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia MO 65201. National Taiwan
University 1977. Also, internal medi-
cine. Board certified. Available.
INTERNAL MEDICINE— Harry D.
Burack M.D., 5548 Waterman PL, St.
Louis, MO 63112. Albany 1978. Also
gastroenterology. Board certified. Part-
nership, group, solo. Available.
Z.UA Farooqui, M.D., Plaza Prc
fessional Bldg., Bayshore Rd. an
Greenwood Ave., Box 238, Villas, N
08251. Aurangabad Medical Colleg
(India) 1972. Board eligible. Group c
partnership. Available.
Aditi Gupta M.D., 27 Sturbridge D
West, Piscataway, NJ 08854. Lac
Hardinge (India) 1980. Board eligibl
Clinic/hospital or group. Available.
H.L. Kirschenbaum, M.D., 780 Woolle
Ave., Staten Island, NY 10314. Ne
York Medical College 1977. Boar
eligible. Also, gastroenterology. Par
nership, group, full-time hospita
Available.
Quang T. Nguyen, M.D., 15 V
Englewood Ave., Bergenfield, NJ 0762
Saigon (South Vietnam) 196'
Subspecialty, nephrology. Boar
eligible. Any type practice. Available.
Claudia Anne Pollet, M.D., 61 L
Parkway Dr., Baltimore, MD 212L,
Mount Sinai 1981. Board eligibl
Salaried position in emergency room
clinic, or urgent care center. Availably
Paul V. Renda M.D., 3206 Myra St
Apt. D, Durham, NC 27707. Mour
Sinai 1981. Board eligible. Solo, grouj
clinic (preferably southern NJ). Avai
able.
Richard B. Schwarz, M.D., 8300 De
Longpre Ave., Apt. 204, Los Angeles, G
90069. NYU 1979. Subspecialb
nephrology. Board certified. Grouj
HMO, hospital. Available.
Gopal Shah, M.D., 100 Caton Ave., Ap
2-G, Brooklyn, NY 11218. M.R Medic?
College (India) 1976. Board eligibl
Group. Available.
Neil Tarkin, M.D., 6700 192nd SI
Fresh Meadows, NY 11365. New Yor
Medical 1978. Also, internal medicim
Board certified (IM). Any type practiq
Available.
Steven Wolinsky, M.D., 1404 E. 15 St
Brooklyn, NY 1 1230. Case Western Re
serve 1980. Group or partnershij
Available.
NEPHROLOGY — Quang T. Nguyen, M.D
15 W. Englewood Ave., Bergenfield, Ni
07621. Saigon (South Vietnam) 196'
Also, internal medicine. Board eligibl'!
Any type practice. Available.
Richard B. Schwarz, M.D., 8300 De
Longpre Ave., Apt. 204, Los Angeles, Gi
90069. NYU 1979. Also, internal med
cine. Board certified (IM). Group, HMC
hospital. Available.
OBSTETRICS / GYNECOLOGY— Balwaj
K. Chhatwal, M.D., 6416 Fairfield Ave
Berwyn, IL 60402. Delhi (India) 197f:
Group, partnership, solo. Available.
Sheela Choubey, M.D., 1 Zirkel Ave
Piscataway, NJ 08854. Poona (Indie;
1 977. Board eligible. Group or partnei
ship. Available.
Edwin R Guzman, M.D., 1200 E. 98t)
St., Brooklyn, NY 11236. New Yor
Medical 1980. Board eligible. Group o
partnership. Available Septembe
1984.
Atul S. Sheth, MID., 2951 S. King Di
Chicago, IL60616. T.N. Medical Colleg
MEDICAL SOCIETY OF NEW JERSE
594
THE JOURNAL OF THE
ndia) 1972. Specializing in infertility,
^productive endocrinology. Board
lig'ible. Partnership, single or multiple
roup practice, academia Available.
;mest A. Topran, M.D., 3523 Dew-
erry-Southem Oaks, Shreveport, LA
1118. Louisiana State 1980. Group or
artnership. Available.
DIATRICS — Dorothea H. Gross, M.D.,
64 Boonton Turnpike, Lincoln Park,
|J 07035. Geneva (Switzerland) 1950.
Tinic, group, emergency room, hospi-
al, pharmaceutical research (salaried),
ivailable.
otsumam Sidharthan, M.D., 222
orkshire Ct„ Old Bridge, NJ 08857.
Calicut Medical College (India) 1976.
Ioard eligible. Available.
DIOLOGY/ NUCLEAR MEDICINE—
'onrad P. Erlich, M.D., 1243 Beacon
>t„ Apt. 3B, Brookline, MA 02146. Bos-
on 1976. Board certified. Group or
artnership. Available,
lindy M. Horrow, M.D., 131 Pond
(rook Rd., Chestnut Hill, MA 02167.
Medical College of Pennsylvania 1980.
'ioard eligible. Group, HMO, academia
livailable.
iubhash S. Pujara M.D., Box 39 IB, Rt.
, Andalusia AL 36420. B.J. Medical
College (India) 1969. Board certified
radiology); board eligible (nuclear
oedicine). Group, partnership, solo,
ivailable.
RGERY, GENERAL— Sara A. Case,
M.D., 284 Quinby Rd„ Rochester, NY
4623. Virginia 1975. Board eligible.
Iroup — general surgery in moderate-
ized city. Available August 1984.
tuben J. Delgado, M.D., 7514 Oriental
r., San Antonio, TX 78244. Puerto
tico 1976. Also, vascular surgery.
Ioard certified. Single or multi-
pecialty group or solo. Available
lugust 1984.
Leonardo A. Garduno, M.D., 2170 S.
loebbert Rd., Apt. 1-109, Arlington
leights, 1L 60005. University of the
last (Philippines) 1968. Any type prac-
ice. Available.
'ames M. Stem, M.D., 600 Vista Court,
Vaynesboro, PA 17268. Jefferson
958. Board certified. Solo, with free-
lorn to practice in broad spectrum of
urgery, including vascular and frac-
tures. Available.
RGERY, ORTHOPEDIC — S.N.
jaraiya M.D., 88-125A 153rd St., Apt.
|l-F, Jamaica NY 1 1432. Baroda (India)
974. Solo. Available August 1984.
: RGERY, VASCULAR— Ruben J.
j)elgado, M.D., 7514 Oriental Tr„ San
Antonio, TX 78244. Puerto Rico 1976.
Uso, general surgery. Board certified
GS). Single or multispecialty group or
olo. Available August 1984.
I X) LOGY— Kiritkumar M. Pandya,
|4.D„ 950 49th St., Apt. 9-A, Brooklyn,
4Y 11219. Baroda (India) 1970. Board
ligible. Group, partnership, solo. Avail-
able.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains.
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins The warm
tingling flush which may follow
each dose of LIPO-NICIN'-''' 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding
Write for literature and samples
(br<2532)THE brown PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057
REFER TO |
PDHl
If s Not What You Know,
Its How You Record It.
Most busy
physicians
find continuing
medical education,
credits easier to
Collect than
to remember.
So the Academy
of Medicine of
New Jersey is offer-
ing an easy system
for recording and reporting
CME credits for AMA recognition
as well as Medical Society and
professional organization membership.
A computerized CME recordkeeping
system is available to every New Jersey
physician. All you do is send us a
reporting card (which your office staff can
complete).
We'll keep
your
records
and keep
you
informed
semi-
annually
of your
accumulation.
This service is free to Academy
members. Non-members (whom
we encourage to join) pay $30 per year.
If you're interested, complete and mail this
coupon.
Note: The Medical Society of New
Jersey accepts these CME Reports as
documentation to meet CME
membership requirements.
Please register me for AMNJ's computerized CME record-keeping service.
Name
Address
City
State
Zip
Telephone Number
Vour New Jersey Medical License No. (five numerical digits only).
Academy member: Yes □
No □ Please enclose check
Interested in Academy membership: Yes □ No □
Mail to: Academy of Medicine of New Jersey, 2 Princess Road, Lawrenceville, NJ 08648
596
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS '
:ME calendar
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
This list is compiled through the coop-
iratdon of the Committee on Medical
Education of the Medical Society of New
Jersey, the Academy of Medicine of New
Jersey, the New Jersey Chapter of the
American Academy of Family Phy-
sicians, and the Office of Continuing
Medical Education of the UMDNJ. For
information on accreditation, please
contact the sponsoring organization(s),
Indicated by italics— last line of each
item.
CARDIOLOGY
Sept.
2 1 Advanced Cardiac Life Support-
Provider
22 7:00 P.M. — Helene Fuld School of
Nursing, Camden
23 (West Jersey Health System and
AMNJ)
MEDICINE
Sept.
6 Evaluation and Assessment of the
Allergic Child
9 AM. — Freehold Area Hospital
(AMNJ)
20 Ontogeny of the Immune System
27 Immune Responses and
Regulation
4-6 P.M. —Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
NEUROLOGY/PSYCHIATRY
Aug.
2 Neurological Diagnosis in
Psychiatric Syndromes
9 Attention Deficit Disorder
1 6 The Animal Connection
30 Premenstrual Syndrome —
Psychiatric and Medical
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
Sept.
5 Computer and Clinical Psychiatry
9: 1 5 AM. -4:45 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
6 Late Onset Schizophrenia
13 Depression: Current Management
and Future Directions
20 Social Management of Breast
Cancer and Surgery
12 noon- 1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
12 Cognitive Rehabilitation in a
Geriatric Medical Center
8:30 AM.-4 P.M.— Bldg. 93, VA
Medical Center, Lyons
(VA Medical Center and AMNJ)
12 The New Antidepressants
1-2:30 P.M.— Bldg. 93, VA Medical
Center, Lyons
(VA Medical Center and AMNJ)
20 Symposium— New Frontiers in
21 Cognitive Rehabilitation
22 All day — Hyatt Regency, Princeton
(Robert Wood Johnson, Jr.
Lifestyle Institute and Natl. Head
Injury Foundation)
OBSTETRICS/GYNECOLOGY
Aug.
1 5 Drugs, Alcohol, and the Pregnant
Woman
8:30 AM. -3:15 P.M. — Monmouth
Medical Center, Long Branch
(Div. of Alcoholism, NJ State Dept
oj Health, and AMNJ)
RADIOLOGY
Sept.
18 Nuclear Magnetic Resonance
12 noon — St. Mary’s Hospital,
Orange
(AMNJ)
SURGICAL SPECIALTIES
Sept.
20 Thoraco-Abdominal Aneurysm
5:15-6:15 P.M. — Shore Memorial
Hospital, Somers Point
(Shore Memorial Hospital and
AMNJ)
MISCELLANEOUS
Sept.
5 Computers in
Medicine / Psychiatry
9:15 AM. -4:45 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation andAMN i.
19 CME Workshop
9 AM. -4 P.M. — MSNJ Executive
Offices, Lawrenceville
(MSNJ and AMNJ)
VOL. 81 -NUMBER 7— JULY 1984
597
CME Information
Essentials and Guidelines
for Accreditation of
Sponsors of Continuing
Medical Education*
Guidelines to the Essentials have
been developed in order to explain in
greater detail the meaning and ap-
plication of the Essentials and to
provide information to sponsors on
how they can comply with the Es-
sentials. These guidelines are not
intended to limit the manner in
which sponsors may meet the re-
quirements for accreditation. Exam-
ples cited are intended only for clari-
fication, not as indications of
preferences or priorities. The Guide-
lines follow the organizational
structure of the Essentials. The text
of the introduction and each Essen-
tial with its explanation and
rationale is given first, followed by
the corresponding Guidelines.
INTRODUCTION
The Accreditation Council for
Continuing Medical Education
(ACCME) conducts a voluntary ac-
creditation program for institutions
and organizations providing con-
tinuing medical education (CME).
By evaluating and granting recog-
nition to an institution or organiza-
tion whose CME program substan-
tially complies with the standards or
Essentials, the ACCME seeks to im-
prove the quality of CME and to as-
sist physicians in identifying CME
programs which meet these stand-
ards.
The ACCME recognizes that the
professional responsibility of phy-
sicians requires continuous learn-
ing throughout their careers, ap-
propriate to the individual physi-
cian’s needs. The ACCME also rec-
ognizes that physicians are respon-
sible for choosing their own CME
and evaluating their own learning
achievement. The Essentials, there-
fore, are designed to encourage and
foster self-directed physician par-
ticipation in CME, in which physi-
cians assume full reponsibility for
the choice of their CME activities in
accordance with their perceived
needs, individual preferences of
learning methods, and practice set-
tings. Sponsors should take into
consideration the needs and
interests of potential physician par-
ticipants in planning their CME ac-
tivities, and encourage these physi-
cians to assume active roles in the
planning process.
In the Essentials, the ACCME has
identified certain elements of or-
ganization, structure, and method
which appear to contribute signifi-
cantly to the development of con-
tinuing medical education. They are
presented here in the Essentials for
Accreditation of Sponsors of Con-
tinuing Medical Education (Essen-
tials).
The Essentials are made up of
those requirements which a sponsor
substantially must meet for ac-
creditation. An explanation and
rationale also are provided. The Es-
sentials should prove valuable as a
resource for physicians planning
their own CME and for sponsors de-
signing CME programs.
The ACCME will review the Essen-
tials on a continuing basis and will
modify them as knowledge and ex-
perience dictate.
It is important to note that the
ACCME does not accredit individual
CME activities, but institutions and
organizations for their overall pro-
gram of CME. The overall program
consists, at least in part, of one or
more educational activities, de-
veloped according to these Essen-
tials, which provide direct teacher-
participant interaction.
The following definitions will be
useful in reviewing the Essentials
and in gaining an understanding of
the accreditation process:
Continuing Medical Education
(CME): Continuing medical educa-
tion consists of educational ac-
tivities which serve to maintain, c
velop, or increase the knowledj
skills, and professional performan
and relationships that a physici;
uses to provide services for patien
the public, or the profession. T
content of CME is that body
knowledge and skills generally re
ognized and accepted by the pi
fession as within the basic medic
sciences, the discipline of clinic
medicine, and the provision
health care to the public.
This broad definition of CME rc
ognizes that all continuing educ
tional activities which assist phy:
cians in carrying out their pr
fessional responsibilities more effe
tively and efficiently are CME.
course in management would be a
propriate CME for physicians i
sponsible for managing a heal
care facility; a course in education
methodology would be appropria
CME for physicians teaching in
medical school; a course in practi
management would be appropria
for practitioners interested
providing better service to patiem
Not all continuing educational a
tivities which physicians may e
gage in, however, are CME. Phyt
cians may participate in worthwhi
continuing educational activiti
which are not related directly
their professional work, and the:
activities are not CME. Continuir
educational activities which r
spond to a physician's noi
professional educational need ij
interest, such as personal financi
planning, and appreciation of liter
ture or music, are not CME.
Purpose of CME Accreditatio:
To assure physicians and the publ
that CME activities meet accept!
standards of education.
CME Accreditation: The reco
nition accorded eligible institutioi
and organizations which meet tl
Essentials.
Program of CME: The overall CM
program of a sponsor consists of oi
or more educational activities cor
sistent with the Essentials.
CME Activity: A coherent educ
tional offering which is based upc
defined needs, and explicit obje
tives, educational content, ar
methods.
*From the Accreditation Council for Co
tinuing Medical Education, Office of tl
Secretary, P.O. Box 245, Lake Bluff,
60044.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
598
i Sponsor: An institution or or-
lization assuming responsibility
CME.
\ Participant: A physician en-
*ed in CME.
The Essentials: The document
ich provides information regard-
|f ACCME accreditation and the
ndards which must substantially
met for a sponsor of CME to be
redded.
*rogram of CME: Accreditation is
inted on the basis of the sponsor’s
nonstrated ability to plan and im-
ment CME activities in ac-
dance with the Essentials. The
onsor’s overall program may in-
de occasional CME activities that
not fully meet the standards for
?ds assessment, well-defined ob-
tives, curricular design, and
duation. These activities are part
the accredited sponsor’s overall
IE program as long as the spon-
; exercises responsibility for these
ivities through its recognized
IE administrative unit. The or-
liization should identify those
IE activities within its overall pro-
im which meet the Essentials.
E ESSENTIALS
Che following Essentials comprise
j: criteria, or standards, by which
*ible sponsors of continuing
dical education are evaluated in
ler to determine their qualifi-
ion for accreditation by ACCME.
Essential #1: The sponsor shall
ve a written statement of its con-
uing medical education mission,
mally approved by its governing
dy. The mission statement shall:
describe the goals of the overall
IE program in a concise manner;
indicate the scope of the CME ef-
t; 3) outline the characteristics of
J potential participants; and 4) de-
ibe the general types of activities
d services provided,
n order to provide quality CME, it
essential to have a written
ssion statement which has been
reed upon by the governing body,
is statement outlines what is ex-
eted of the CME organization and
ves as a basis for a more objective
duation of its ability to meet its
ssion. Without such a document,
ere may be misunderstandings as
the scope and nature of the CME
ivities undertaken. With an
reed-upon mission statement, the
IE organization more easily can
seek needed support from its gov-
erning body to accomplish its re-
quired functions.
The mission statement identifies
what the sponsor desires to ac-
complish through its overall pro-
gram of CME. It describes the educa-
tional goals of the overall program in
terms of content or extended learn-
ing, the physicians for whom the
educational program is intended,
and the general kinds of educational
activities and services which will be
used to accomplish these goals. It is
desirable to relate the educational
goals of the overall program, as
found in the CME mission state-
ment, to the primary purpose or
mission of the sponsor as an institu-
tion or organization.
The mission statement should
serve as an effective point of refer-
ence for individual CME program-
ming and evaluation of the overall
program. The mission statement
should be reviewed periodically in
the light of experience and revised if
necessaiy.
Essential #2: The sponsor shall
have established procedures for
identifying and analyzing continu-
ing medical educational needs and
interests of prospective participants.
The sponsor shall: 1) document the
processes used to identify CME
needs including data sources which
go beyond the sponsor’s own per-
ception of need, and 2) state the
overall needs identified by the above
processes and indicate how this
assessment is used in planning
educational activities.
Identification and analysis of
CME needs (needs assessment)
provides the basis for formulating
educational objectives and planning
educational activities. Needs
assessment results in a statement
specifying instructional intent
and/or expected learning outcomes.
Needs may be perceived and/or
identified by both the physician par-
ticipant and the sponsor. Setting
priorities for identified needs will as-
sist the sponsor in planning educa-
tional activities.
Educational needs and interests
refer to any knowledge, skill, or at-
titude that physicians either should
or wish to acquire, develop, or rein-
force. Participants should be treated
as professionals with respect for
their knowledge, experience, and
self-motivation. Therefore, a goal for
every CME activity should be to in-
crease, or at least to maintain, the
participants’ desire to continue
their medical education. This im-
portant goal of CME should be kept
in mind when designing the activity,
i.e. choosing the educational
methods, selecting instructors, and
determining methods of evaluation.
The way that educational subjects
are presented, as well as the instruc-
tor’s manner with participants, in-
fluence the motivation of physicians
not only to learn during the activity
but to continue learning after the
activity is completed.
The sponsor may use a wide vari-
ety of procedures to identify needs,
such as a sample survey interview of
prospective participants, analysis of
self-assessment examination re-
sults, epidemiological data patient
care audit, or a search of current
literature or consensus of experts in
a particular field. The sponsor
should attempt to weigh the relative
importance of the needs identified,
and determine the planning of CME
activities and use of resources with
these priorities in mind.
The term “need” usually connotes
some degree of necessity or obli-
gation. The necessity or obligation
may arise from a physician’s sense
of responsibility to maintain or im-
prove personal professional ac-
tivities. This necessity or obligation
also may arise from external require-
ments of some organization or agen-
cy such as a licensure board, certify-
ing agency, specialty society, or hos-
pital staff.
The term interest connotes an
educational want or desire. Physi-
cians may desire some knowledge,
skill, or attitude not perceived as
necessarily directly applicable to
their medical practice. For instance,
a physician may desire to learn more
about a particular development in
his medical research yet realize that
this knowledge may not be the only
or primaiy criterion of choice for
physicians.
An educational need may be real
yet exist independent of the aware-
ness of the physician. A real need
becomes a perceived need when the
physician is aware of it. Unless phy-
sicians perceive an educational need
as their own, any CME activity based
on that need is unlikely to be suc-
cessful in effecting real learning or
in attracting participants. If the
educational need is real, but un-
perceived, physicians may need as-
L. 81— NUMBER 7— JULY 1984
599
sistance recognizing that need.
An educational need is not the
same as a performance need. Needs
identified by quality assurance pro-
grams, for instance, do not neces-
sarily indicate a lack of knowledge or
skill. Sponsors may wish to analyze
performance needs to determine
whether there is, in fact, a need for
physician learning and not assume
that performance deficiencies can
be addressed successfully through
educational activities.
Essential #3: The sponsor shall
have explicit objectives for each
CME activity. The sponsor shall: 1)
state the educational need(s) which
the individual activity addresses: 2)
indicate the physicians for whom
the activity is designed: 3) list any
special background requirements of
the prospective participants; 4)
highlight the instructional content
and/or expected learning outcomes
in terms of knowledge, skills, and/or
attitudes; and 5) make these objec-
tives known to prospective partici-
pants.
Clearly stated objectives provide
prospective participants with a re-
alistic understanding of the nature
and purposes of the CME activity.
This allows prospective participants
to select educational activities
which meet their needs. It also helps
sponsors to target educational ac-
tivities to meet explicit needs. A
CME activity which takes place over
a period of time, e.g. weekly grand
rounds, may be covered by a single
set of objectives.
The development of objectives
serves three functions: 1) assisting
sponsors in planning, designing,
and implementing educationally ef-
fective activities: 2) assisting spon-
sors in evaluating the quality of
CME activities: and 3) assisting pro-
spective participants in judging
whether or not a CME activity meets
their needs or interests. The ade-
quacy of a sponsor’s development of
objectives depends on how well
these objectives fulfill these three
functions.
Explicit objectives means that the
objectives are clear and of sufficient
detail so that they are capable of
fulfilling the three functions
outlined above. Objectives need not
be overly detailed.
These objectives should relate to
the needs identified in Essential #2.
Such needs might include updating
existing medical knowledge or tech-
nical skills, the learning of new con-
cepts or methods, or the sharing of
new ideas and experiences to stimu-
late the development of knowledge
or skills.
An objective that is conceived
properly and is stated clearly con-
stitutes an important link in the
educational chain. Good objectives
are formulated from identified needs
or interests and written in terms
that facilitate evaluation. Clear ob-
jectives aid in judging the success of
the CME activity.
In contrast to goals, which are
general and long-range, objectives
are specific, short-range, and more
action-oriented. Objectives may be
defined with respect to instructional
content, levels of knowledge or per-
formance, degrees of skill or tech-
nique, and changes in attitude or
behavior relating to patient care
that are the desired results of the
CME activity.
Keeping one or more of the follow-
ing questions in mind may help in
developing good objectives: Will at-
tainment of these objectives meet
the identified needs? What will the
participants be expected to know or
be able to do as a result of the CME
activity? How is the participant’s at-
titude or behavior expected to
change? How do these relate to pa-
tient care or other professional ac-
tivities? Can attainment of the ob-
jectives be measured or evaluated?
The Essentials place great import-
ance on the principle that physi-
cians are responsibile for choosing
their own CME, in accordance with
their perceived needs, preferred
learning methods, and practice set-
tings. In accordance with this prin-
ciple, sponsors may make known to
prospective participants the objec-
tives of the activity, indicate the
physicians for whom the activity is
designed, list any special back-
ground requirements for effective
participation, and state the educa-
tional methods that will be used.
This information should appear on
promotional materials and printed
programs. Individual educational
objectives need not be stated for
each part or unit of an activity if the
objectives are apparent or if they are
summarized in the CME activity de-
scription.
Each CME activity should be de-
scribed in terms of the broad or
specific groups of physicians for
whom it may have value. For exam-
ple, a particular CME activity max
intended to bring a new med;
concept to the attention of an enr?
specialty group or to a range oh
lated specialty groups, or it migh x
a more limited concept intended :
a subspecialty group.
A prospective CME participa
should be informed as to the le 1
of skill or knowledge required for il
participation in, and compref -
sion of, each CME activity. For
stance, it may be suggested U
each participant review a specie
area of regional anatomy before ] r
ticipating in a CME activity in oi r
to better comprehend the spec:
surgical procedure or diagnoi
technique to be introduced or s
cussed. One also might be requej ::
to review the broad classificatioi
tumors of a specific area in pn
aration for a better understand it
of the more detailed presentation;
the management of tumors of 1 is
area
When parts or units of a CME c
tivity are integrally related to the i-
tire activity, one set of objectns
may be sufficient. This app s
whether the parts or units of an :
tivity are united in time, e.g. a th
day conference, or appear as distnt
units over a period of time, e.g. gr; d
rounds.
Essential #4: The sponsor si ll
design and implement educatic il
activities consistent in content ; d
method with the stated objecti1 s.
The sponsor shall: 1) design and l-
plement educational activities
sponsive to the characteristics >f
prospective participants, such is,
knowledge levels, professional :
perience, and preferred learn g
styles; 2) document use of systci-
atic planning procedures; and )
make educational content £ d
methods known to prospecie
paticipants.
After the identified needs h e
been translated into explicitly staid
educational objectives it is impi-
tant to design and implem t
educational activities in a way 1 1
facilitates meeting the objective
The selection and organization 1
content, and decisions about edu -
tional formats, methods, media, £ 1
faculty should be based upon w t
seems most effective and efficient !
meeting these objectives. Th js
same elements pertain to sponso 1
CME activities which provide ini -
mation and assistance to physick 5
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
600
igaged in self-directed learning.
The term sponsor is compre-
ensive, referring to the institu-
on/organization accredited for its
derail CME program. Implicit in the
se of this term is the fact that a
umber of people with different
isponsibilities may be involved in
ae design and implementation of
le CME activities that comprise the
ME program. A group that is rep-
;sentative of the institutional/
rganizational membership (usually
esignated the education commit-
?e) usually has responsibility for
ie operational aspects of the CME
rogram.
Design and implementation of
ME activities implies systematic
lanning. Planning of any CME ac-
vity, ranging from a one-hour con-
Tence to a multiday symposium,
ivolves a sequence of tasks, with
ach successive step depending
pon completion of the previous
ne.
An initial step should be to review
valuation data from previous simi-
ir CME activities when available.
A major consideration is the
haracteristics of prospective par-
icipants, i.e. for whom the CME ac-
ivity primarily is intended/de-
igned, viz. certain specialists or the
ntire medical staff. After identifying
he target group, one should make
ireliminaiy assumptions regarding
articipants’ current knowledge
ivels in the subject matter, past pro-
fessional experiences, and types of
gaming methods appropriate for
hat group and subject.
A closely related task is needs
issessment (Essential #2), i.e. “Why
s this CME activity being held?”
Vhatever the method used to iden-
ify needs, the assessment should
letermine whether acquisition of
nformation, knowledge, or skill is
he basic need, or whether a re-
lew/refresher, an update, or presen-
ation of new concepts is required.
A next and important step is the
levelopment and statement of objec-
tives for the CME activity (Essential
f3). There should be a clear, concise
tatement of what the participants
hould learn and/or be able to do as
i result of the CME activity. Such a
tatement, evolving from the
Previous planning activities,
irovides a useful focus for the par-
icipants and for the teachers. This
i specially can be valuable when
here are many and varied CME ac-
j OL. 81— NUMBER 7^JULY 1984
tivities available to the physician.
For the teacher, it should determine
preparation and selection of teach-
ing methods.
Selection of faculty, i.e. the per-
son^) who will be invited to conduct
the CME activity, is determined by
several factors: foremost, the avail-
ability of competent and enthusi-
astic individuals; the level of ex-
pertise required; the extent of prep-
aration necessary; and available re-
sources. Good faculty often can be
identified with one’s own organiza-
tion. External faculty should be
selected to meet the defined objec-
tives and not primarily for their
charisma
Effective planning requires that
the format and educational methods
be appropriate to the objectives. Suf-
ficient time should be allocated for
faculty and participants to ac-
complish the objectives. Optimal op-
portunity should be given to partici-
pants to be involved actively in im-
plementation of the CME objectives.
Evaluation of the activity (Essen-
tial #5) is an integral part of the
planning and should be in-
corporated into the design. Whether
the activity is simple or complex, or
short or long, some form of evalu-
ation should be planned. At a mini-
mum, participants should provide
feedback regarding achievement of
the objectives, i.e. were CME needs
met. Additionally, effectiveness of
the educational method, the faculty,
and other aspects of the activity can
be critiqued. Evaluation completes
the process cycle and should lead to
refinements in planning for future
CME activities.
Other tasks pertain more directly
to implementation of CME objec-
tives and include scheduling, ar-
rangements for facilities, and audio-
visual equipment/services prep-
aration of educational materials, i.e.
handouts, slides, and transparen-
cies. Decisions regarding these
aspects should be made in collabora-
tion with, and under the guidance
of, the person(s) responsible for the
CME program.
The Essentials encourage and
foster self-directed learning in the
sense that physicians actively
should be responsible for their own
continuing medical education.
Physicians are encouraged to iden-
tify their own educational needs and
interests and to develop plans to
meet these needs and interests. Ef-
fective planning for a self-designed
educational program would include
the elements of identification of
need, development of educational
objectives, choice of appropriate
educational activities, and evalu-
ation. The educational activities
chosen may include a variety of
forms, from reading to formally or-
ganized courses. A time schedule for
completing the self-designed pro-
gram is highly advisable.
Some physicians may desire as-
sistance in developing self-designed
educational programs. Consultation
with those experienced in planning
CME activities, experienced medical
librarians, or physician specialists
may be helpful. Sponsors may wish
to offer assistance to physicians in
developing “self-directed” individual
CME programs. Sponsors who have
the resources may desire to offer
this assistance and are encouraged
to do so.
Documentation of the systematic
planning procedures is an integral
part of an institutional/organiza-
tional CME program. Again, whether
regularly-scheduled intrainstitu-
tional activities, periodic con-
ferences, courses, seminars, sym-
posia, or workshops, it is useful to
have a written record of education
committee or other planning group
meetings; correspondence relating
to faculty, facility, financial arrange-
ments, as indicated; needs assess-
ment; objective-setting; and evalu-
ation. Such documentation need not
be complicated or time-consuming,
but should be sufficient for the par-
ticular CME activity. Patently, this
information and related data are
valuable in monitoring the overall
program, ensuring continuity, plan-
ning future CME activities, and as
evidence of fulfillment of require-
ments for continued accreditation.
Prospective participants should
be informed in advance about the
specific content and format for a
CME activity, for several reasons: 1)
it enables them to select CME con-
tent that is relevant to their needs
and/or interests: 2) in locales where
many CME offerings are available,
advance information allows the
physician to choose activities that
are best suited to personal needs
and time allocation; 3) when some
preparation is desirable or required,
this can be accomplished, thereby
enhancing the extent and value of
participation; 4) they will know the
601
extent and type of participation ex-
pected of them; and 5) in some re-
spects, this information represents
truth in advertising. Physicians who
are uninformed or misinformed will
be disgruntled, with the result that
they may not participate in future
activities. Advance publicity reflects
proper planning and conveys a
favorable impression to the physi-
cian regarding the potential worth
of the CME activity.
Essential #5: The sponsor shall
evaluate the effectiveness of its over-
all continuing medical education
program and component activities
and use this information in its CME
planning. The sponsor shall: 1) peri-
odically review the extent to which
the sponsor’s CME mission is being
achieved by its educational ac-
tivities; 2) show that these evalu-
ations assess: the extent to which
educational objectives are being
met; the quality of the instructional
process; participants’ perception of
enhanced professional effectiveness;
3) use evaluation methods which are
appropriate and consistent in scope
with the educational activity; and 4)
demonstrate that evaluation data
are used in planning future CME ac-
tivities.
The systematic gathering of evalu-
ation data and their analysis, in-
cluding evaluation of individual
CME activities, is necessary for the
sponsor to assess the degree to
which the overall program fulfills its
CME mission. It also will guide the
planning of future activities and
permit rational decisions about im-
proving the educational program.
This Essential requires that the
sponsor periodically review the ex-
tent to which the sponsor’s educa-
tional goals for the overall program
of CME, as contained in the mission
statement are being achieved. The
sponsor should do this annually. In
order to evaluate the effectiveness of
the overall CME program, the spon-
sor must evaluate individual CME
activities which have been planned
and conducted. These evaluations
must assess the extent to which the
educational objectives have been
met, the quality of the educational
process, and the participants’ per-
ceptions of enhanced professional
effectiveness.
Evaluation methods must be ap-
propriate and consistent in scope
with the educational activity. A well-
constructed evaluation form com-
pleted by participants at the con-
clusion of the educational activity
provides useful data Often the
evaluation form also provides an op-
portunity for participant sugges-
tions for future educational ac-
tivities. Immediate indepth evalu-
ation by selected participants, as
well as followup surveys, may be veiy
helpful.
If the educational objective con-
cerns the learning of a skill, direct
observation of the participant’s
ability to perform that skill is an ex-
cellent method of evaluation.
Tests may be used when ap-
propriate. It is difficult, however, to
construct a valid and reliable test,
and as a result, data from tests often
are questionable. The sensitivity of
participants should be considered.
Care should be taken that testing
does not adversely affect the physi-
cian’s desire to continue learning.
Although the ultimate purpose of
continuing medical education is to
improve medical care, measure-
ments of physician performance, the
quality of medical care and patient
outcomes should not be the only
criteria used in assessing the quali-
ty of the educational activity and of
the degree of learning by partici-
pants. While keeping in mind that
many factors beyond the control of
CME planners influence medical
care, sponsors are encouraged to at-
tempt to assess the effect of their
CME activities on medical care
when this is feasible.
There are other evaluation tech-
niques that are not based on educa-
tional objectives, but may be useful
to the sponsor. Participant attention
and enthusiasm, active involvement
in discussion, the kinds of ques-
tions asked and comments made for
instance, may be observed and re-
corded. The number of physicians
who voluntarily return to a spon-
sor’s CME activity may be another
indication of quality.
The Essentials require that the
sponsor demonstrate that evalu-
ation data are used in planning fu-
ture CME activities. Evaluation data
collected but not used in future
planning are worthless.
Essential *6: The sponsor shall
provide evidence that management
procedures and other necessary re-
sources are available and effectively
used to fulfill its continuing medical
education mission. The sponsor
shall: 1 ) document an organizational
structure for CME and its adminis
tration, designating an entity re
sponsible for CME and delineatin
its authority; 2) identify responsibl
individuals who will maintain cont
nuity of administration; 3) describ
an internal review and contrc
procedure, including budgetar
practices, to ensure effective utilize
tion of resources in fulfilling th
CME mission; 4) provide a budge
for the overall CME program and it
major components; 5) utilize compc
tent faculty; 6} provide appropriat
facilities for CME programs; and 7
have mechanisms to record anc
when authorized by the partic
pating physician, to verify partial
pation.
Whether sponsors of CME ar
large or small, adequate manage
ment and control are necessary t
assure quality educational activity
In addition, adequate resource
must be available in order for CM1
activities to be relevant, effective
and efficient for physicians.
Administration— The sponso
must document an organization
structure for CME and its adminis
tration, designating an entity re
sponsible for CME and delineating
its authority. This entity may be ai
individual or a committee. If an indi
vidual is designated, there should b
an advisory committee, with a ma|
jority of physicians, which takes at
active role in planning. Minutes o
committee meetings should be kept
CME committees should have rep
resentation of departments and/o
services when appropriate anc
feasible.
The organizational structure
must clearly indicate the authority
of the entity responsible for CME!
and should show how this entity re
lates to the governing body of the1
organization and effectively super
vises CME planning of other units o
the organization. CME policies anc
procedures should be documented
There should not be undue de
pendence on one individual so tha
in the event of absence or illness, the
CME program flounders. The spon
sor must identify responsible indi
viduals who will maintain conti
nuity of administration. Members o
committees should be appointed sc
their terms expire on varying dates
Administrative staff support shoulc
be sufficient to fulfill the CME
mission. The terms of office of the
persons responsible for CME shoulc
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
602
2 of sufficient duration to assure
mtinuity of administration.
Utilization of Resources— To
lsure effective utilization of re-
)urces in fulfilling the CME
lission the sponsor must have an
iternal review and control
rocedure. This procedure need not
2 elaborate. The procedure should
?rmit the entity responsible for the
derail program of CME to effectively
onitor and supervise the planning
id implementation of individual
ME activities.
Included in the internal control
-ocedure is preparation of a budget
id the use of sound fiscal practices
i administering the overall CME
rogram. The budget should be ade-
jate to meet the objectives of the
ission statement. The sponsor is
icouraged to have a separate CME
idget, but should be able at least,
early to identify the CME budget
hen not separate from other items,
idividual departments or services
an organization may have their
vn CME budgets, but the entity re-
>onsible for the overall CME pro-
am should have some responsi-
lity for the allocation and utiliza-
on of resources.
Competent Faculty — The sponsor
ust utilize competent faculty. Fac-
ty for a CME activity should be
elected not only for their knowledge
the subject matter, but for their
oility to communicate and to facili-
te learning. The faculty’s attitudes
ad manner of treating participants
•e also important considerations.
Appropriate Facilities — Sponsors
ust provide appropriate facilities
l
l
I
>L. 81— NUMBER 7— JULY 1984
and materials for CME activities. Ap-
propriate means conducive to learn-
ing. As an example, access to an ade-
quate, up-to-date library and
audiovisual facilities are important.
Facilities may be selected for a
CME activity at a site which offers
opportunities for recreation and re-
laxation. These opportunities
should complement, rather than de-
tract from, the CME activity itself.
Publicity should present the CME
activity as the major incentive to
physicians who may choose to par-
ticipate.
Records of Attendance — The spon-
sor must have a mechanism to re-
cord physician participation at CME
activities. Records should be kept for
at least six years. Sponsors must
have a mechanism to verify physi-
cian attendance when authorized by
the participating physicians.
Essential #7: The sponsor shall
accept responsibility that the Essen-
tials are met by educational ac-
tivities which it jointly sponsors
with nonaccredited entities. The
sponsor shall: 1) provide evidence
that it participates integrally in the
planning and implementation of
each jointly sponsored CME activity;
and 2) conduct an evaluation of each
jointly sponsored CME activity.
An accredited sponsor may be
asked by organizations which are
not accredited to jointly sponsor
CME activities, so they may have ac-
credited sponsorship. When an ac-
credited sponsor agrees to joint
sponsorship it must provide as-
surance that the Essentials are met.
The Essentials require that a
sponsor accept responsibility that
accreditation standards are met by
CME activities it jointly sponsors
with nonaccredited institutions and
organizations. An accredited in-
stitution or organization has the
same responsibility for an activity it
jointly sponsors as for an activity it
sponsors. The sponsor should
provide information on these jointly
sponsored activities when re-
surveyed for accreditation and must
demonstrate that it has participated
integrally in the planning and im-
plementation of these activities.
Jointly sponsored activities must
be consistent with the sponsor’s
mission statement. The sponsor
must conduct an evaluation of each
jointly sponsored CME activity in
the context of its mission statement.
The name of the accredited spon-
sor should appear on all promo-
tional materials and on the printed
program of the jointly sponsored ac-
tivity. If more than one accredited
sponsor jointly sponsors a CME ac-
tivity, one should assume respon-
sibilty for the activity and this
should be indicated clearly on the
promotional materials and printed
programs.
Some local chapters or affiliates of
national organizations neither are
independently accredited nor speci-
fically included in the accreditation
of the national organization. The ac-
credited national organization
should have care that it not be listed
as the joint sponsor of CME ac-
tivities of such local chapters or af-
filiates unless the requirements of
this Essential are met.
603
Letters to the
Editor
Child Find
April 11, 1984
Dear Doctor Krosnick
A statewide CHILD FIND system to
identity unserved handicapped chil-
dren from birth through 21 years of
age recently has been re-established
by the New Jersey Department of
Education in the Regional Cur-
riculum Services Unit-Central, 75
Racetrack Road, East Brunswick NJ
08816. The activities of CHILD FIND
include the operation of a toll-free
hotline (800-322-8174) to respond
to parental and professional re-
quests for assistance and to act as
a clearinghouse for information re-
garding programs and services for
handicapped children in New Jersey.
Project CHILD FIND provides the
most up-to-date information on pro-
grams and services available for
handicapped or potentially handi-
capped children throughout New
Jersey. All phone calls are handled in
an efficient and confidential manner
to facilitate appropriate services for
all inquiries. Project CHILD FIND
also has outreach and media infor-
mation prepared for distribution in
its efforts to comprehensively seek
out children in need of special ser-
vices.
I would welcome any questions
you or your readers may have re-
garding Project CHILD FIND and
gladly will forward specific printed
information you may require. The
toll free number operates from 8:30
A.M. to 4:30 p.m. Monday through Fri-
day.
(signed) Frances Stromsland
CHILD FIND Project Coordinator
Mandatory Assignment
May 4, 1984
Dear Doctor Krosnick
Thursday, April 12, 1984, was a
crucial day for American medicine.
On that day, the AMA fought back
an attempt to impose involuntary
servitude by the government upon
every practicing physician in the
United States.
If mandatory assignment had
passed, you would have been re-
quired to sign an agreement with
your hospital to accept Medicare as-
signment for all inpatient care or
lose all staff privileges. In effect, you
would not have been able to work at
your profession.
If it had not been for organiz]
medicine, that would be your pligt
today. If it had not been for the v-
untaiy freeze in fees, a mandate/
freeze now would be in effect.
This incredible effort to prevet
your financial enslavement mit
not go unnoticed by you. Any doci d
who does not belong to the Ah
should not let this day pass withe (
writing out a check for his du .
What a small price to pay for th r
service to you.
On the local level, the outstandi >
work of Morton Farber, M.D., mi t
be brought to your attention,
heeded the call for assistance at 1 >
county society office and spent l|s
day off making telephone calls a :
sending telegrams to other docto
hospital administrators, and to cc-
gressmen to prevent this devastj-
ing legislation from being passe
Jean Bruno was county represen -
tive on a state auxiliary delegatie.
who spent Wednesday, April 1 1, ajl
Thursday, April 12, in Washingt i
visiting congressmen and spread! $
our message.
It was doctors like Morton Farb .
spouses like Jean Bruno, and <
ganized medicine who made the c
ference. The war is not over, bun
significant battle has been won. Y i
will share in the fruits of that v -
tory. In good conscience, you mit
share the cost.
In order to build on what we he ?
won, we should honor the fee free ?
requested by the AMA and your stc
and county societies. It is our tin
to send a message to the Amerie i
people. Let us not fail.
(signed) Donald J. Holtzman, M .
President, Union Cour?
Medical Sociu
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
604
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lie, City University of New York,
le essay, “A Feast for Aesculapius;
storical Diets for Asthma and Sex-
1 Pleasure,” is delightfully il-
strated by medieval woodcuts,
limonides, center stage, rec-
lmends that a severe asthmatic
ould prophylactically precede love-
iking with hot clear chick soup.
ACT. Jarvis succinctly covers food
Idism, cultism, and quackery,
cumenting the dismal impression
it P.T. Bamum was right. The fol-
ding items are exceptionally time-
and critical: biological activity of
enium (RF. Burh); absorption
d metabolism of dietary choles-
i'ol (S.M. Grundy); placenta in
trition (S.J. Pilistine and M.E.
’»L. 81— NUMBER 7— JULY 1984
Fant); nutrition in renal failure (M.
Walser); ischemic heart disease and
lipids in blood and diet (RA.
Stallones); endocrine responses to
protein-calorie malnutrition (D.J.
Becker); availability of trace ele-
ments (RM. Forbes and J.W. Erd-
man, Jr.); carnitine (P.R Borum);
normal and abnormal Cu and Zu
metabolism (RA DiSilvestro and
RJ. Cousins); niacin (L.M. Hen-
derson); stable-isotope methods in
nutrition research (D.E. Mathews
and D.M. Bier); endemic goiter and
cretinism (J. Matovinovie); individ-
ual food consumption in the U.S.
(P.B. Swan); and protein metabolism
and injury (J.M. Kinney and D.H.
Elwyn). Herman Baker, Ph.D.
Annual Review of
Neuroscience , Volume 7
W. Maxwell Cowan (ed). Palo Alto,
CA Annual Reviews, Inc., 1984. Pp.
494. Illustrated. ($27)
This book is the seventh in a
series of annual reviews of progress
in the neurosciences. Thirty-six
authors present 17 individual
papers on different topics, each of
which deals in detail with a single
area of neuroscience research. Their
subjects are almost exclusively in
the basic neurosciences, so that lit-
tle of a clinical nature is covered.
Some examples are discussions of
neuronal growth factors, proteolysis
of neuropeptides, intracellular H+
mechanisms, and cell adhesion in
the nervous system. Most of the
papers include historical back-
ground and recent advances as well
as divergent current opinions and
theories about each subject.
A few papers will prove of interest
to the practicing neurologist or neu-
rosurgeon. One deals with the en-
dorphins, enkephalins, and dynor-
phins, and their related neuropep-
tides and opioid receptors in rela-
tion to stress, analgesia, and
cardiovascular control. The authors
describe the complexity of bio-
chemical and physiological inter-
relationships of these substances as
“dizzying,” and admit that potential
interactions seem infinite. Other
somewhat more clinical papers dis-
cuss the neural basis of language,
intracellular neural implants, en-
dogenous pain control systems, and
withdrawal from opioid drugs.
These reviews are very complete
and well done. They impress one
with the complexity and sophisti-
cation of current neuroscience re-
search, but are chiefly oriented to
basic sciences. This book is heavy
reading indeed for the average prac-
titioner.
Stanley C. Leonberg Jr., M.D.
Arthroscopy ; Diagnosis
and Surgical Practice
S. Ward Casscells, M.D., (ed). Phila-
delphia, PA Lea & Febiger, 1984.
Pp. 192. Illustrated. ($40)
The contributing authors to this
compendium of arthroscopic knowl-
edge will be well known to or-
thopedists who became interested
in this aspect of their specialty sev-
eral years ago, when the American
Academy of Orthopaedic Surgeons
sponsored courses on the subject. A
hardy nucleus of the pioneers in this
field were present as faculty, and one
saw virtually the same faces, no mat-
ter where he went to study arthro-
scopic surgery. These teachers have
recorded their remarks in the form
of textbook chapters, brought
together by the course chairman, S.
Ward Casscells.
Like the courses which preceded
the book, and like all texts compiled
in this fashion, the outcome rarely
is fully satisfying. That is not to say
that the book is without merit. Be-
cause the contributions are individ-
ual efforts, there tends to be a lack
of cohesiveness, and the process
leaves gaps and creates redundan-
cies, as when, for example, the “fish-
mouth” tear of the meniscus is de-
scribed and diagramed by Drs.
Zarins and Mclnemy in chapter 6,
and again by Dr. Metcalf in chapter
17.
The first half of the book is theo-
retically devoted to diagnostic
arthroscopy, but in chapter 5, Dr.
Casscells wanders into a brief dis-
cussion of abrasion arthroplasty, a
surgical technique, and appears to
dismiss its effectiveness. This
procedure is advocated by Lanny
Johnson who notably is absent from
the list of authors, and who perhaps
deserves an opportunity to defend it
in a book described by the publisher
as “comprehensive." Synovial dis-
ease is discussed in chapter 4, and
synovectomy in chapter 5. but there
is no reference to, or description of,
any technique for accomplishing
synovectomy arthroscopically,
605
although others, including one of
this book’s contributors (Dr. Met-
calf). have advocated that method.
Patellofemoral joint disorders are
discussed in the diagnostic section
of the book and by Drs. Shybut and
McGinty in the surgical chapters. In
neither place can one find a descrip-
tion of the portals used in evaluating
patellofemoral joint mechanics, or of
the normal and abnormal findings
in those conditions affecting
patellofemoral dynamics, except for
mention of the percentage of lateral
patellar overhang. Well before the
date of publication of this book, the
use of superior portals to evaluate
patellofemoral contact during flex-
ion and extension was well docu-
mented.
One might expect that in a book
such as this, the chapter in the sec-
tion on arthroscopic surgery by Dr.
Kenneth DeHaven on peripheral
meniscus repair would discuss
arthroscopic techniques. Yet,
arthroscopy was used only for
diagnosis, and Dr. DeHaven then
proceeds to describe an open
procedure for meniscal suture. One
brief comment is the sole reference
to closed meniscal repair: “It is likely
that these procedures will be per-
formed arthroscopically in the fu-
ture.” Yet, the tools and instruments
exist, and other arthroscopists have
described the approach and
produced teaching material.
RW. Jackson, M.D., another of the
pioneers, writes in his foreword that
this book is “truly a state-of-the-art
publication.” Unfortunately, as in
computers and other “high tech”
fields, what is state-of-the-art today,
is obsolete either tomorrow, before
delivery, or publication date.
In this book, the degree of ob-
solescence appears to depend on
how long it has been since the
author updated his chapter’s ma-
terial after joining the lecture
circuit. Dr. Glick’s chapter on the
use of the laser beam looks to the
future. The remainder of the book is
a look backwards, by people who
clearly have earned the right to do
so, and from whose observations all
surgeons doing arthroscopic
procedures can learn. The drawings
clearly illustrate the points to be
emphasized, and the photographs of
arthroscopic pathology are clear and
very well reproduced.
I recommend this book especially
to the student arthroscopist, but
also to those with an established
interest in the field, with the caveat
that is not the last word on the sub-
ject. No observer of so rapidly ad-
vancing a field should expect a text
to be that.
Robert A. Goldstone, M.D.
A Colour Atlas oj
Diabetes
Arnold Bloom, M.D., and John Ire-
land, M.D. Chicago, IL, Year Book
Medical Publishers, Inc., 1980. Pp.
119. Illustrated. ($55)
This is not a textbook of diabetes,
but a presentation in graphic form
of the clinical and histological mani-
festations of this disease. The
authors have divided their atlas into
ten chapters starting from etiology,
through manifestations, pathology,
and complications. They do not deal
with management of diabetes.
In British fashion, the text is terse,
pithy, yet quite comprehensive —
each chapter followed by excellent
photographs in color. Particularly
striking are the photographs of the
eye and kidney pathology. While this
volume will not meet a student’s re-
quirement for a textbook of diabetes,
the many pictures can be a valuable
supplement in the study of this il
ness.
Samuel E. Einhom, M.I
Varicose Veins , Related
Diseases, and Sclero-
therapy: A Guide for
Practitioners
H.I. Biegeleisen, M.D. Montreo
Canada, Eden Press, 1984. Pp. 24
Illustrated. ($35)
“A new branch of medicine the j
requires special knowledge, trair
ing, and skill for its practice” refer
to sclerotherapy as applied to vaj
icose veins, its complications, an
other related diseases. According t ,
the author, this is the first manu;
of its kind that deals with all know
sclerosing techniques as personal!
practiced for the last 50 years. Th
pervading theory throughout thi
labor of love is that all disorders re
lated to inherited fascial defects an
accompanied by tissue weaknes
and degeneration best are treated b
sclerotherapy. Headed by varicos
veins, the list includes stasis ulcer
lymphedema, hemorrhoids, reck
prolapse, pilonidal cysts, hydrocelef
hernias, low back syndromes, and
host of others. Repetitious descrip
tions of sclerosing agents and tech
niques as applied to scattered ancij
tomical sites were weakly enhance
by suboptimal illustrations. Th
bibliography also is extended by rep
etition.
Dr. Biegeleisen should hav
heeded his comment “Although thi I
manual was first written 40 year
ago, it never was published becaus
it soon was rendered obsolete.” Thi| ’
guide for practitioners is perhap
more of historical interest rathe
than practical.
Joseph Alpert, M.E
606
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
OBITUARIES
1
Dr. Joel A. Bernhard
Joel A. Bernhard, M.D., a member
of our Essex County component,
died on February 27, 1984. Bom in
1900, Dr. Bernhard was graduated
from Jefferson Medical College,
Pennsylvania, in 1940. An anesthe-
siologist, Dr. Bernhard was affiliated
with the Hospital Center, Orange.
Dr. Bernhard was a member of the
American Medical Association.
Dr. Leo Bimbaum
At the grand age of 89, Leo
Bimbaum, M.D., a retired physician
jof our Union County component,
died on January 14, 1984. Bom in
New York City, Dr. Bimbaum re-
ceived his medical degree from New
York Medical College in 1931. Prior
to establishing a practice in psy-
chiatry in Scotch Plains, in 1964, he
had been a general practitioner in
Sunnyside, New York and had
served on the staff of various Vet-
erans Administration facilities
VOL. 81— NUMBER 7-JULY 1984
throughout the United States. Dr.
Bimbaum was a Diplomate of the
American Board of Psychiatry and a
Fellow of the American Psychiatric
Association. He retired from the ac-
tive practice of medicine in 1975
and had been living in California
until his final illness.
Dr. Jacob L. Drossner
Jacob Louis Drossner, M.D., an in-
ternist for 42 years prior to his re-
tirement in 1979, died on April 20,
1984. Bom in 1913, in Philadelphia,
Dr. Drossner received his medical
degree from the University of Penn-
sylvania’s School of Medicine in
1936, graduating first in his class.
He established a practice in his
specialty in Camden; in 1961 he
moved to Pennsauken. Dr. Drossner
had been affiliated with Cooper Hos-
pital, Camden, and Garden State
Hospital, Marlton. He was board
certified in internal medicine, was a
member of the American Medical As-
sociation, a member of our Camden
component, and an associate
professor at Thomas Jefferson Uni-
versity, Philadelphia He served in
the medical corps of the Army of the
United States, and received the Sil-
ver Star and the Purple Heart.
Dr. Clarence T. Hill
Clarence T. Hill, M.D., a general
practitioner in Rahway for over 40
years prior to his retirement in
1973, died on March 30, 1984. Bom
in Madison, Dr. Hill received his
medical degree from Howard Univer-
sity College of Medicine in 1932. He
had been on the staff at Rahway
Memorial Hospital, and was a mem-
ber of the American Medical As-
sociation and of our Union County
component. Dr. Hill was 81 years of
age at the time of his death.
Dr. John E. Leach
A Paterson physician for 41 years,
John E. Leach, M.D., died on April 7,
1984. Bom in 1908, Dr. Leach
earned a medical degree from Jef-
ferson Medical College, Philadelphia,
in 1933. Affiliated with Valley Hospi-
tal, Ridgewood, and Chilton Hospi-
tal, Pompton Plains, Dr. Leach was
an internist. A member of our
Passaic County component and of
the American Medical Association,
Dr. Leach was a Diplomate of the
American Board of Internal Medi-
cine and a Fellow of the American
College of Physicians.
Dr. Edward M. Mancene
One of the Bergen’s County’s
senior members, Edward Michael
Mancene, M.D., died on April 22,
1984. A native of New Jersey, bom
in 1 906, Dr. Mancene was graduated
from New York Homeopathic Medi-
cal College in 1934. He practiced
general medicine in Little Ferry for
50 years until his retirement in
1976. Dr. Mancene was affiliated
with Hackensack Medical Center
where he had been associate direc-
tor of the department of family prac-
tice. He was a Fellow of the American
Academy of Family Practice, and had
been a member of the American
Medical Association. Dr. Mancene
served as a delegate to the Medical
Society of New Jersey’s House of Del-
egates for 20 years. He had been ac-
tive in community affairs, serving as
Little Ferry’s school physician for 13
years; surgeon to the police and fire
departments; and advisory physi-
cian to the first aid corps for 35
years. Dr. Mancene also had been
vice president of the Little Ferry
board of health. During World War II
he served with General George Pat-
ton’s Third Army and was awarded
a Silver Star and five bronze stars
for valor.
Dr. Leo C. Rocco
A member of our Monmouth
County component, Leo C. Rocco,
M.D., died on February 25, 1984.
Bom in 1909, Dr. Rocco earned a
medical degree from Creighton Uni-
versity School of Medicine, Ne-
braska, in 1935. A surgeon. Dr.
Rocco was affiliated with Riverview
Hospital, Red Bank, and Monmouth
Medical Center, Long Branch.
Dr. Maslah Saul
At the age of 62, Maslah Saul,
M.D., a member of our Cumberland
County component, died on March
22, 1984. Dr. Saul was a graduate of
the Faculty of Medicine University of
Paris, France in 1952. A family prac-
titioner, Dr. Saul was affiliated with
the State School Hospital, Vineland.
607
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
608
It's Not What You Know,
dlt.
It’s How You Rec
Most busy
physicians
find continuing
medical education
credits easier to
collect than
to remember.
So the Academy
of Medicine of
New Jersey is offer-
ing an easy system
for recording and reporting
CME credits for AMA recognition
as well as Medical Society and
professional organization membership.
A computerized CME recordkeeping
system is available to every New Jersey
physician. All you do is send us a
complete).
We'll keep
your
records
and keep
you
informed
semi-
annually
of your
reporting card (which your office staff can
accumulation.
This service is free to Academy
members. Non-members (whom
we encourage to join) pay $30 per year.
If you're interested, complete and mail this
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Note: The Medical Society of New
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documentation to meet CME
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Please register me for AMNJ's computerized CME record-keeping service.
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Mail to: Academy of Medicine of New Jersey, 2 Princess Road, Lawrenceville, N) 08648
L. 81— NUMBER 7— JULY 1984
609
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Computers, Medical Management
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Financial
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Personnel
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531, 560-561, 571
538, 596
539
Cover II, 562, 575
548
611, 612
609, 610
610
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JEI EY
CLASSIFIED ADVERTISEMENTS
VRDIOLOGIST/INTERNIST — Board
rtified in both specialties. Seeks posi-
>n solo, group or hospital based. Write
>x No. 90, JMSNJ.
TERNIST — Board eligible, general in-
mist with extensive emergency room
perience. Seeking group practice of
temal medicine or emergency room
isition. Northern NJ area Available,
ill 2 1 2-645-46 1 6. Steven Wolinsky, MD.
irriculum vitae and references avail-
le upon request.
DDIATRICIAN— Seeks part time posi-
>n. Pediatric clinic or office. Middle-
;ed, board certified. Planning to seek
ivate practice. Prefer Monmouth or
;ean County. Willing to work nights
id weekends. Write Box No. 73, JMSNJ.
LEDED PHYSICIANS — For successful
41 known walk-in medical office center,
■ntral NJ. Full and part time, skilled
rsonable American-trained MDs. Send
J to E. V. McGinley, MD, 1005 N. Wash-
gton Avenue, Green Brook, NJ 08812.
H-968-8900.
IACTICE FOR SALE — Twenty-year-
1, solo, general practice in South-Cen-
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id 1 1/2 hours from NYC. Busy, efficient,
gh net. Just negotiated a seven year
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me building. Lovely suburban area
th top-rated school systems. A good
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home. Hospital across town. Write Box
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on. Excellent opportunity. Write Box
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FOR SALE— House/Office. Fully
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FOR SALE — X-ray, Fisher 300 MS, veiy
little use, reasonable. Call 201-627-2544.
FOR SALE— ECG portable COMPUTER,
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FOR SALE or RENT — Kearny. Fully
equipped and furnished medical office
building including patients' records.
Comer location on main street. Call after
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FOR SALE or RENT — Central Jersey. For
immediate occupancy new, modem,
energy efficient rental 500 to 2,000
square feet available. 31,000 residents
within three mile radius. Close to Phila-
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shore area Internists and specialties
needed. Ideal for main/satellite office.
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FOR RENT — Professional office for rent.
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FOR RENT — Professional office space for
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route. Call 201-731-1900.
FOR LEASE — Attractive, modem medi-
cal building, Morris Avenue, Union
Center, Union, NJ. Office for lease. 750
square feet, large, private adjoining park-
ing lot, 1st floor, no steps . . . will build to
suit. Phone 201-688-2480.
OFFICE TO SUBLET— Medical office to
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OFFICE TO SHARE— Bergenfield. Cen-
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ing, furnished, 900 square feet. $450.
Five minutes from hospitals. Summer
1984. Write or call Ronny Meier, MD, 297
S. Washington Ave., Bergenfield, NJ
07621. 201-385-8350.
OFFICE FOR SHARE or RENT— New
Brunswick, Highland Park area Fur-
nished, 700 square feet. Ample parking.
Close to the hospital. $500/month plus
utilities, for rent. For share, $300/month
including utilities. Call 201-572-5050 or
572-7553.
.TE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
)RD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
mbers, hyphenated words. Count name and address as five words, telephone number as one word, and "Write Box No. 000,
1 JMSNJ" as six words. COPY DEADLINE: Fifth of preceding month.
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERfY
The Journal •» ▼ v
rx[K™ New Jersey
AUGUST 1984
library
U.C. SAN FRANCISCO
SEP 7 1984
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The Library
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Check this list
against your
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Send this coupon
for no-obligation
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off the savings
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i 75 Montgomery St.,
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or 1-800-B LANKA G
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Name:
Address:
Tel. No.
Best Time To Call.
The Journal
of the Medical
Society of
New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jersey. This special
issue illuminates the beginnings of our health care system and the growth
of medical care: essays highlight those talented individuals who devoted
themselves to this system, and commentaries present the development of
specialized care in associated fields of medicine. Plus a special photography
section highlighting three statewide exhibits.
Copies of this issue are available by sending $5.00 (check or money
order) to MSNJ, Two Princess Road, Lawrenceville, NJ 08648. All MSNJ
members will receive one copy of this issue.
Name
Address
Enclose a $5.00 check or money order for each copy.
81— NUMBER 8— AUGUST 1984
613
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 766
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D, (Essex) Glen Ridge
President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
Hemy J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr„ M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
August 1984
Publication Committee
Paul J. Hirsch. M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba, M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa, M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) excit
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Prints
Co. Whole number of issues 965. Member’s subscription ($10) is included in Society dues. Rates for nonmembs,
$20 outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, To
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and addition
entry office. Copyright 1984 by the Medical Society of New Jersey.
614
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER.‘ X
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Jote: If you ’ re new to medical practice in N.J. . . .
’em don’t have to buy commercial
nalpractice insurance
VIES S . T ODD , M . D . , Chairman/Board of Directors, Medical In ter-Insurance Exchange of New Jersey
you made your decision to establish yourself
New Jersey, you no doubt heard horror
tries about our professional liability insurance
Dblems. The legal risks we assume in this
siness have grown so far out of proportion
it many commercial underwriters have been
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reer, you have an alternative to commercial
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ssible with long-term peace of mind.
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A professional service message from the
Medical Inter-Insurance Exchange of N .J.
Two Princess Road, Lawrenceville NJ 08648
(609) 896-2404
L. 81— NUMBER 8— AUGUST 1984
615
The Journal
of the Medical
Society of
New Jersey
AUGUST 19,1
Features
6 1 9 Membership Newsletter
623 Physician Legal Bulletin
629 Professional Liability Commentary
63 1 Editorials
635 Hospital Governing Boards
Contributions
637 Geriatric Imperative: Should Community Hospitals Have Geriatric
Units?
MA. Nevins, M.D., Woodcliff Lake
643 Geriatric Imperative: The Interface Between the Acute Hospital and
Long-Term Care
W.J. Kane, M.D. , and D.C. Kennie, M.G., CH.B., Mount Holly
647 Geriatric Imperative: An Opportunity for Change
R. B. Milch, Passaic
65 1 Geriatric Imperative: Geriatric Assessment Programs
L. Z. Rubenstein, M.D., Sepulveda, CA
655 Geriatric Imperative: The Acutely 111 Elderly
LA. Joel EcLD., Newark
66 1 Geriatric Imperative: Summary Statement of ACP Study Group
MA. Nevins, M.D., S. Alexander, M.D., F. Chinard, M.D., E. Harris, M.D.,
M. Wallen, M.D., Woodcliff Lake
663 Pharmacological Basis of Therapeutics: Gossypol, An Oral Male
Contraceptive?
S. M. Penningroth, Ph.D„ Piscataway
667 The Impaired Physicians Program: Another Kind of Impairment
E.D. Reading, M.Div., Lawrenceville
669 Your Congressman Speaks: The Cost of Health Care
Congressman Jim Courter
Doctors’ Notebook
672 UMDNJ Notes, Stanley S. Bergen, Jr„ M.D.
673 MSN J Auxiliary, Grace Gel Iman
673 New Members
674 Physicians Seeking Location in New Jersey
MSN J Departments
677 CME Calendar
68 1 Letters to the Editor
683 Book Reviews
685 Obituaries
687 Information for Authors
On The Cover: The Serenata Quartet
is a fine example of the challenge and
opportunity of the new geriatric im-
perative. Members of this excellent
string quartet include: Beverly
Palmer, violin (61); Stuart Jolly, violin
(65); David Rounds, cello (77); and Kay
Knudsen, viola (78). Photo by Joe
Dixon.
_
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER! V
616
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* 81— NUMBER 8— AUGUST 1984
617
An added complication...
in the treatment of bacterial bronchitis
Brlel Summary. Consult the package literature lor prescribing
information.
Indications and Usage: Ceclor® (cefaclor, Lilly) is indicated in the
treatment of the following infections when caused by susceptible
strains of fhe designated microorganisms
Lower respiratory infections, including pneumonia caused by
Streptococcus pneumoniae (Diplococcus pneumoniae), Haemophilus
inlluenzae. andS pyogenes (group A beta-hemolytic streptococci)
Appropriate culture and susceptibility studies should be performed
to determine susceptibility of the causative organism to Ceclor
Contraindication. Ceclor is contraindicated in patients with known
allergy to the cephalosporin group of antibiotics
Warnings. IN PENICILLIN-SENSITIVE PATIENTS, CEPHALOSPORIN
ANTIBIOTICS SHOULD BE ADMINISTERED CAUTIOUSLY THERE IS
CLINICAL AND LABORATORY EVIOENCE OF PARTIAL CROSS-
ALLERGENICITY OF THE PENICILLINS AND THE CEPHALOSPORINS
AND THERE ARE INSTANCES IN WHICH PATIENTS HAVE HAD
REACTIONS, INCLUDING ANAPHYLAXIS. TO BOTH DRUG
CLASSES
Antibiotics, including Ceclor, should be administered cautiously to
any patient who has demonstrated some form of allergy, particularly
to drugs
Pseudomembranous colitis has been reported with virtually all
broad-spectrum antibiotics (including macrolides. semisynthetic
penicillins, and cephalosporins), therefore, it is important to consider
its diagnosis in patients who develop diarrhea in association with the
use of antibiotics Such colitis may range in severity from mild to
life-threatening
Treatment with broad-spectrum antibiotics alters the normal flora
of the colon and may permit overgrowth of Clostridia Studies
indicate that a toxin produced by Clostridium difficile is one primary
cause of antibiotic-associated colitis.
Mild cases of pseudomembranous colitis usually respond to drug
discontinuance alone In moderate to severe cases, management
should include sigmoidoscopy, appropriate bacteriologic studies, and
fluid, electrolyte, and protein supplementation When the colitis does
not improve after the drug has been discontinued , or when it is
severe, oral vancomycin is the drug of choice for antibiotic-
associated pseudomembranous colitis produced by C. difficile. Other
causes of colitis should be ruled out
Precautions: General Precautions — If an allergic reaction to Ceclor
occurs, the drug should be discontinued, and, it necessary, the
patient should be treated with appropriate agents, eg., pressor
amines, antihistamines, or corticosteroids
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms. Careful observation of the patient is
essential II superinfection occurs during therapy, appropriate
measures should be taken .
Positive direct Coombs' tests have been reported during treatment
with the cephalosporin antibiotics. In hematologic studies or in
transfusion cross-matching procedures when antiglobulin tests are
performed on the minor side or in Coombs' testing of newborns
whose mothers have received cephalosporin antibiotics before
parturition, it should be recognized that a positive Coombs' test may
be due to the drug
Ceclor should be administered with caution in the presence of
markedly impaired renal function. Under such conditions, careful
clinical observation and laboratory studies should be made because
safe dosage may be lower than that usually recommended
As a result of administration of Ceclor. a false-positive reaction for
glucose in the urine may occur This has been observed with
Benedict's and Fehlmg’s solutions and also with Clinitest® tablets but
not with Tes-Tape* (Glucose Enzymatic Test Strip, USP, Lilly)
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history of gastrointestinal disease, particularly
colitis.
Usage in Pregnancy— Pregnancy Category B— Reproduction
studies have been performed in mice and rats at doses up to 1 2 times
the human dose and in ferrets given three times the maximum human
dose and have revealed no evidence of impaired fertility or harm to
the fetus due to Ceclor There are, however, no adequate and
well-controlled studies in pregnant women Because animal
reproduction studies are not always predictive of human response,
this drug should be used during pregnancy only if clearly needed
Nursing Mothers — Small amounts of Ceclor have been detected in
mother's milk following administration of single 500-mg doses
Average levels were 0 18, 0.20, 0 21 , and 0 16 mcg/ml at two, three,
four, and five hours respectively Trace amounts were detected at one
Some ampicillin-resistant strains of
Haemophilus influenzae— a recognized
complication of bacterial bronchitis*— are
sensitive to treatment with Ceclor.1 6
In clinical trials, patients with bacterial bronchitis
due to susceptible strains of Streptococcus
pneumoniae. H. influenzae, S, pyogenes
(group A beta-hemolytic streptococci), or multiple
organisms achieved a satisfactory clinical
response with Ceclor.7
Pulvules®, 250 and 500 mg
hour The effect on nursing infants is not known. Caution should be
exercised when Ceclor* (cefaclor, Lilly) is administered to a nursing
woman.
Usage in Children — Safely and effectiveness of this product for use
in infants less than one month of age have not been established
Adverse Reactions: Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2.5 percent of patients
and include diarrhea (1 in 70)
Symptoms of pseudomembranous colitis may appear either during
or after antibiotic treatment Nausea and vomiting have been reported
rarely.
Hypersensitivity reactions have been reported in about 1.5 percent
of patients and include morbilliform eruptions (1 in 100) Pruritus,
urticaria, and positive Coombs' tests each occur in less than 1 in 200
patients Cases of serum-sickness-like reactions (erythema
multiforme or the above skin manifestations accompanied by
arthritis/arthralgia and. frequently, fever) have been reported These
reactions are apparently due to hypersensitivity and have usually
occurred during or following a second course of therapy with Ceclor.
Such reactions have been reported more frequently in children than in
adults Signs and symptoms usually occur a fewfdays alter initiation
of therapy and subside within a few days after cessation of therapy
No serious sequelae have been reported Antihistamines and
corticosteroids appear to enhance resolution of the syndrome
Cases of anaphylaxis have been reported, half of which have
occurred in patients with a history of penicillin allergy.
Other effects considered related to therapy included eosinophilia
(1 in 50 patients) and genital pruritus or vaginitis (less than 1 in 100
patients)
Causal Relationship Uncertain— Transitory abnormalities in clinical
laboratory test results have been reported Although they were of
uncertain etiology, they are listed below to serve as alerting
information for the physician.
Hepatic— Slight elevations of SGOT, SGPT, or alkaline phosphatase
values (1 in 40)
Hematopoietic— Transient fluctuations in leukocyte count,
predominantly lymphocytosis occurring in infants and young children
(1 in 40)
Renal — Slight elevations in BUN or serum creatinine (less than 1 in
500) or abnormal urinalysis (less than 1 in 200)
(061782R)
• Many authorities attribute acute infectious exacerbation of chronic
bronchitis to either S. pneumoniae or H inlluenzae. "
Note: Ceclor is contraindicated in patients with known allergy to the
cephalosporins and should be given cautiously to penicillin-allergic
patients
Penicillin is the usual drug of choice in the treatment and
prevention of streptococcal infections, including the prophylaxis of
rheumatic fever See prescribing information.
References
1. Antimicrob Agents Chemother ,8. 91, 1975.
2 Antimicrob Agents Chemother , 11 470, 1977.
3 Antimicrob. Agents Chemother , 73 584 . 1978
4 Antimicrob. Agents Chemother , 12 490, 1977
5 Current Chemotherapy (edited by W. Siegenthaler and R Luthy),
II 880 Washington, D C American Society for Microbiology.
1978
6 Antimicrob Agents Chemother , 73 861 , 1978
7 Oata on file. Eli Lilly and Company
8 Principles and Practice of Infectious Diseases (edited by G.L
Mandell. R.G Douglas, Jr , and J E Bennett), p 487 New York:
John Wiley & Sons, 1979
© 1982. ELI LILLY AND COMPANY
Additional information available to
the profession on request from
Eli Lilly and Company
Indianapolis, Indiana 46285
Eli Lilly Industries. Inc.
Carolina. Puerto Rico 00630
■i
I :l
618
■
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER^Y
HE MEDICAL SOCIETY OF NEW JERSEY VOLUME 14
\ 5RKSHOP ON CME NEEDS ASSESSMENT AND
STE SURVEYS
Dn September 19, 1984, between the hours of 9:00
A and 4:00 p.m.. The Academy of Medicine of New
vrsey and the Medical Society of New Jersey jointly
\ II sponsor a workshop at the MSNJ Headquarters,
To Princess Road, Lawrenceville.
This program will feature noted experts in the CME
fid discussing practical approaches to needs
csessment and site surveys governed by ACCME es-
5 itials.
Those physicians acting in DME capacities, hospital
£ d specialty society program chairmen, program or
ME committee members as well as nonphysician
ME support staff should attend.
Mark your calendar now for this important meeting.
Tgistration materials have been sent. For additional
(formation or clarification, contact the Executive Of-
l es at (609) 896-1717.
. HA TO PRODUCE FEE FREEZE POSTER
A poster that shows physician support for a one-year
; freeze appeared in the May 25 edition of American
edical News. It may be tom out and displayed in
ception areas. Here is the wording of the poster: “I
ive voluntarily frozen my fees for one year beginning
bruary 1984. I am supporting the policy of the
nerican Medical Association and other medical so-
eties to do my fair share in holding down the cost
medical care. If it is difficult for you to pay my fees
licause you are uninsured, unemployed, or on a fixed
come, let’s talk about it.”
A limited supply of extra posters is available from the
iepartment of Consulting Services. Contact Heidi
jough, communications coordinator, Department of
onsulting Services, AMA (312) 645-4413.
ABY DOE REGULATIONS INVALIDATED
A U.S. court struck down the “Baby Doe” regulations,
ding in favor of the AMA and other medical organiza-
ons in the lawsuit they brought last March 12.
In response to the favorable decision, John J. Coury,
I D., chairman of AMA’s board of trustees, and Frank
Jirka, M.D., AMA president, issued the following joint
statement: “The American Medical Association is
elated with the ruling of the United States district
court for the southern district of New York invalidating
the final Baby Doe. This ruling affirms that the federal
government does not belong in cases involving the
medical treatment of severely handicapped newborns.
The AMA believes the care of these newborns should
be the responsibility of the parents, in consultation
with their physicans and other professionals on the
medical treatment team.”
FOREIGN-TRAINED PHYSICIANS
Foreign-trained physicians account for 21.2 percent
of the physician population in the United States, ac-
cording to the AMA Division of Survey and Data Re-
sources. The 7,591 Canadian physicians, who were
counted in a separate category, represented 1 .5 percent
of the physicians in this country. India trains the larg-
est number of foreign medical graduates now practic-
ing in the United States (17,031 or 16 percent of this
country’s 106,586 FMGs) followed by the Philippines
(13,323 or 12.5 percent), Mexico (6,793 or 6.4 percent),
and South Africa (3,588 or 3.4 percent).
REQUIREMENTS FOR ISSUING A PRESCRIPTION:
13:35-6.6
(a) Physicians and podiatrists shall provide the fol-
lowing information on all prescriptions:
1. Full name, age, and address of patient;
2. Prescriber’s full name, address, telephone
number, and proper degree designation as appears on
prescriber’s license;
3. Prescriber's BNDD number when required for the
dispensing of controlled substances. (Controlled
Substance Act of 1970);
4. Date of prescription;
5. Name, strength, and quantities of drug or drugs
to be dispensed;
6. Adequate instruction for the patient (P.RN. or “as
directed” alone is not sufficient);
7. Number of refills permitted or time limit for refills
or both;
8. Signature of prescriber;
3L. 81— NUMBER 8— AUGUST 1984
619
9. When preprinted prescription blanks are not
available the full name of the prescriber must be print-
ed or stamped in block letters under the signature of
prescriber;
10. In no instance shall a physician or podiatrist
sign a blank prescription form which does not conform
with the above standards.
(b) Failure to comply with this ruling will subject
the physician to disciplinary sanction in accordance
with the Medical Practice Act.
LEGALIZE USE OF HEROIN
Legislation to establish a four-year program under
which injectable heroin would be made available for
terminally ill cancer patients suffering from intrac-
table pain will be considered by the House of Represen-
tatives. The AMA opposes H.R 5290. They believe that
the bill would establish an inappropriate precedent by
pre-empting the consumer-protection features of the
Food and Drug Administration’s (FDA) new drug ap-
proval process. Moreover, there is no evidence that
making heroin available for the relief of pain from
cancer would provide an additional benefit to patients
since equally effective medications — such as morphine
and dilaudid HP— already are available. We also are
concerned that passage of H.R 5290 could result in an
increase in illicit drug diversion.
MINI-RESIDENCY IN PRESCRIBING CONTROLLED
DANGEROUS SUBSTANCES
The Mini-Residency in Prescribing Controlled
Dangerous Substances is being offered November 13,
1984, at the University of Medicine and Den-
tistry—Rutgers Medical School, Medical Education
Building.
The program is being offered to upgrade physician
knowledge of controlled dangerous substances. There
has been indications that some physicians have en-
countered difficulties with the State Board of Medical
Examiners resulting from irregularities in controlled
dangerous substance prescribing.
The didactic portion will be scheduled for a full 3
days, 9:00 am. to 5:00 p.m., each week for four con-
secutive weeks — a total of 12 days. A 42-hour week
clinical rotation follows the didactic portion.
The Mini-Residency is an effort to assist physicians
who desire to obtain additional training in the use of
controlled dangerous substances either for pro-
fessional upgrading or licensure requirements.
The proposed date for the next Mini-Residency is
November 13, 1984, in New Brunswick. The exact dates
for the didactic portion are Tuesday, November 13,
1984, Wednesday, November 14, 1984, Thursday, No-
vember 15, 1984, Monday, November 19, 1984, Tues-
day, November 20, 1984, Wednesday, November 21,
1984, Monday, November 26, 1984, Tuesday, November
27, 1984, Wednesday, November 28, 1984, Monday, De-
cember 3, 1984, Tuesday, December 4, 1984, and
Thursday, December 6, 1984.
Registration is now open, but limited. The initial
enrollment registration of $200 is nonrefundable.
I
Full payment of the balance of $2100 is due by n
vember 5, 1984. Payment installments will be acce ei:
in accordance with the following schedule: Octobi h
1984, October 22, 1984, and November 5, 1984.
No one will be permitted in the course after No^n
ber 6, 1984, unless full payment is rendered.
If you have any questions regarding the courso
registration, please call 609-757-4676.
PROSPECTIVE RULE: UTILIZATION OF INSURA 1
BENEFITS
The Division has proposed a rule which will ap i
in a subsequent issue of the New Jersey Regisi.
The proposal allows providers to submit claim,
insurance companies by acting as assignee for n
Commissioner, New Jersey Department of Human ?r
vices. The proposal concerns those situations wi
the Medicaid patient has third party coverage, o a
than Medicaid, but the policy holder is not avaibi
to sign the claim form.
AIDS
The New Jersey State Department of Health rece ft
completed pamphlets entitled, “Acquired Immune e
ficiency Syndrome.” The pamphlets published in £ g
lish, Spanish, and French are designed to inform it
general public regarding AIDS and its symptoms, it
pamphlets also discuss how to avoid becoming m
AIDS victim and lists names, addresses, and pbie
numbers of organizations available for additional i-
formation.
These free pamphlets may be obtained by writin ir
calling the New Jersey State Department of Hech,
Communicable Disease Services, Room 702, CN (0.
Trenton, NJ 08625, (609) 292-7300, Monday to Frhy
8:45 AM. to 4:45 P.M.
PHYSICIAN’S CONFERENCE
There will be a Women Physicians’ Leadership Ctf
ference on Saturday, October 27, 1984, at UMEl-
Rutgers Medical School, Medical Education Build g
New Brunswick. For more information, please til
MSNJ, Office of Public Relations, 609-896-1766.
PROSPECTIVE RULE: AUTHORIZATION TO
RELEASE INFORMATION REGARDING
PRESCRIPTIONS
The Division has proposed a rule which will ap( Jr
in a future issue of the New Jersey Register, if
proposal will authorize prescribing practitioners tee-
lease to the Division, or any law enforcement autho y,
information about prescriptions which have been ( id
by PAAD. A statement to this effect already appear: m
the beneficiary’s application.
FINI
“Those who bring sunshine to the lives of otl rs
cannot keep it from themselves.”
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS r
... I
620
CARE FOR YOUR COUNTRY
As an Army Reserve physician, you can serve your
country and community with just a small investment of
your time. You will broaden your professional experience
by working on interesting medical projects in your com-
munity. Army Reserve service is flexible, so it won’t
interfere with your practice. You’ll work and consult with
top physicians during monthly Reserve meetings. You’ll
also attend funded continuing medical education programs. You will all share the
bond of being civic-minded physicians who are also commissioned officers. One
important benefit of being an officer is the non-contributory retirement annuity you will
get when you retire from the Army Reserve. To find out more, simply call the number
below.
CALL COLLECT OR USE THE COUPON AT BOTTOM:
215-443-1703/1705
CPT HARRY SIMPSON
AMEDD Procurement Office
31-D N. York Road
Hatboro, PA 19040
NAMF: .
. MD/DO
SPFCIAI TY:
ADDRESS:
TFIFPHONF- .. -
BEST TIME TO CALL:
(AM/PM)
*L. 81— NUMBER 8-AUGUST 1984
621
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
you practice.
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program,
for more information please call
IBSTETRIC AND
rYNECOLOGIC MALPRACTICE
|MES E.
George, m.d., j.d., and Madelyn S. Quattrone, j.d., lawrenceville*
recent survey sponsored by the
American College of Obstetrics
™ and Gynecologists (ACOG) re-
als that about 60 percent of the respondents have
bn sued more than once, and in New York, 48.8
rcent have been sued three or more times; 49.7 per-
at of ACOG members' professional liability suits
re based on obstetric claims while 41.3 percent were
ib result of gynecological surgery,
utigation against obstetricians and gynecologists
s had a substantial impact on the specialty. Respon-
nts to the survey said that the threat of malpractice
its and the high cost of insurance have caused them
raise their fees, practice medicine more defensively,
d restrict their practice. A significant number of the
ecialists no longer are practicing obstetrics.
Some have speculated that the technological ad-
nces in the specialty have led to increased expecta-
ns on the part of patients. When these expectations
- not met, dissatisfied patients may resort to liti-
tion.
This issue of the Physician Legal Bulletin will high-
ht some troublesome areas in the practice of ob-
■trics and gynecology with a view toward recognizing
•d reducing recurrent problems which trigger liti-
tion.
plaintiff attorneys are rapidly educating themselves
th regard to the medical aspects of obstetrics liti-
tion. For example, the March 1984 issue of Trial
magazine featured an article entitled “Obstetric Negli-
gence: An Introduction to a High-Risk Specialty.” Phy-
sicians likewise may avoid legal pitfalls through knowl-
edge of some of the legal aspects of claims in this area.
Many lawsuits involving birth-related injuries stem
from allegations such as failure to adequately monitor
labor, inappropriate or excessive use of oxytocin, mis-
diagnosed presentation, failure to respond quickly
enough to signs of fetal distress, and failure to perfonn
a timely cesarean section. Obstetric emergencies,
whether immediate or imminent, have given rise to a
significant amount of litigation when damage to the
infant has occurred. A frequently asserted allegation
is the failure of the physician to correctly assess high-
risk pregnancies and to take timely and appropriate
action to reduce the risk of harm to mother and child.
Consider the following account of a recent New Jer-
sey case as reported in 27 ATLA L. Rep. 87, March
1984. At the time of delivery, the mother was post-term
at 44 weeks and markedly obese. Despite notification
of the onset of labor and his awareness of the high-
risk factors, the obstetrician failed to arrive at the
hospital for five hours. A certified nurse midwife, and
*From the Department of Professional Liability Control,
MSNJ, where Dr. George is Director and Editor of PLB and
Ms. Quattrone is Assistant Editor of PLB. Correspondence
may be addressed to A. Ronald Rouse, MSNJ, Two Princess
Road, Lawrenceville, NJ 08648.
>L. 81— NUMBER 8— AUGUST 1984
623
a labor room nurse with minimal training in ob-
stetrical care, performed the delivery without a phy-
sician present. At delivery, the umbilical cord was
wrapped three times around the infant’s head, causing
perinatal asphyxia Further, the infant suffered renal
ischemia, cortical necrosis with azotemia, and
neonatal seizures. As a result, the child sustained
brain damage with left-sided hemiparesis and learning
impairment.
Subsequently, the plaintiffs filed suit against the
defendant obstetrician for the failure to attend the
delivery, alleging that the absence of an obstetrician
deprived plaintiff of the use of an internal fetal heart
monitor rather than an external monitor. Plaintiffs
also sued the labor room nurse for the failure to detect
abnormal decelerations appearing on the fetal heart
monitor tape. The case was settled out of court for
$482,056, with contributions by the obstetrician and
the nurse.
Another common allegation is the failure of the
physician to appreciate and appropriately respond to
indicators of fetal distress. Standards set by the Ameri-
can College of Obstetricians and Gynecologists with
regard to the indications for use of electronic fetal
monitoring as well as monitoring by other means
when such equipment is not available, may be in-
troduced into evidence as standards of care against
which the conduct of the defendant will be measured.
Today, electronic fetal monitoring is the standard in
many hospitals and the failure of the physician to
order such monitoring may be below the applicable
standard of care. Unfortunately, some hospitals regard
storing the fetal monitor tracings as burdensome, and
routinely destroy the fetal monitoring strips. In many
cases the destroyed tracings may deprive the defen-
dant obstetrician of documentary evidence which is
supportive of his defense.
Lawsuits arising out of obstetrical claims which al-
lege injury to the child may be labeled “wrongful birth”
or “wrongful life.” A wrongful birth suit is an action
brought by parents who contend that the negligence
of the physician resulted in the birth of a “defective”
child. Physicians who fail to provide appropriate ge-
netic counseling or who negligently perform a
procedure to prevent the birth of a defective child are
likely targets of wrongful birth suits. Some wrongful
birth suits may be referred to as “wrongful conception”
or “wrongful pregnancy” actions. In these cases, the
plaintiff alleges that the breach of duty (failed abortion,
negligently performed sterilization, or failure to
diagnose an existing pregnancy) resulted in the birth
of a healthy, normal child.
In the case of P. V. Portadirx 179 N.J. Super 465, the
Superior Court, Appellate Division, permitted the
plaintiffs to bring wrongful birth action. Mrs. P. alleged
that she consented to a tubal ligation but that the
physician willfully and negligently performed a fallo-
pian rings procedure instead. Despite the procedure
Mrs. P. gave birth to a normal child.
The court did not allow the plaintiffs to recover any
expenses for raising their normal child but did allow
Mrs. P. to recover for “the pain and suffering accompa-
nying her pregnancy and delivery and for the wages
lost during that period.” Her husband could recover
lor loss of consortium and for the medical expenses
incurred which are attributable to the pregnancy v
delivery.”
Damages sought in wrongful birth cases ma fe
elude expenses related to the unplanned pregrn
and birth, pain and suffering, spousal loss of m
sortium, and lost wages. The parents of damaged h
dren also are likely to seek damages to compel ai«
them for the cost of past, present, and future me (p
and rehabilitative care for the child. Parents also ijt
recover for the emotional damages they have susk it
upon their realization that their child suffers fr i
congenital defect or deformity. Whether a succeS
plaintiff can recover all of these damages depenc.oi
the specific facts and circumstances of the case
Lawsuits alleging wrongful birth may inclu |i
claim by the parents or legal guardian on behalf o;i
child for “wrongful life.” A wrongful life action hi
damaged child's equivalent of the parents’ wroiB
birth action. The claim alleges that, but for the jji
sician’s negligence, the child would not have been ie
to experience the pain and suffering attributable t<|I
deformity and such nonlife would have been be;^
Unlike wrongful birth actions, wrongful life act n
have been received with little favor by the courts, f cl
suits have been rejected in New Jersey and a nuriie
of other states. Courts refusing to recognize wrorra
life as a legal cause of action have emphasized h
social policy that life, with or without major handieps
is more precious than nonlife.
Most courts have found it impossible to calculate
damages sought in wrongful life cases. The renjd
afforded a plaintiff in the civil law is intended t b
remedial or compensatory in order to place the plai il
in the position he would have been in had he not m
injured by the defendant in the first place. There r<
most courts have found it impossible to calculate cm
ages based on the comparison between life in an r
paired condition and the state of nonexistence. Co t
traditionally have been unwilling to place a price i
on nonlife.
Not all courts have found damage in wrongful; f
actions impossible to calculate. The Supreme Cou: c
California and Washington and a Superior Courii
Arizona have upheld wrongful life claims and alio ?
recovery for the extraordinary expenses for mec £
care and special training required by the defeev
child.
A number of wrongful birth cases have been pr 1
cated upon the alleged failure to provide adequate*
netic counseling and prenatal testing. Genetic cour :1
ing, genetic screening, and amniocentesis are imp 1
ant new areas of liability for obstetricians a
gynecologists. A physician may be liable for failinj j
refer a patient to a qualified genetic counselor, fall
to diagnose correctly a genetic condition that is las
manifested in the patient’s child, or for failing to i
form a patient of the consequence of being a car "
of a genetic defect.
Two important New Jersey cases in this area i
volved failure to advise a woman over age 35 of the j ■
of Down’s syndrome and failure to inform parents tja
they were carriers of the genetically transferable < :
ease, cystic fibrosis.
In the latter case, 87 N.J. 53 (1981), the Supre
Court of New Jersey held that physicians may be f
624
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS j
;le for the past, present, and future medical ex-
t ses of a defective child which are attributable to his
i-ase. In that case, the plaintiffs alleged that the phy-
ians had failed to timely diagnose cystic fibrosis in
: r first-born child. As a result, the plaintiffs, un-
ue that they were carriers of a genetically trans-
:ble disease, had a second child. The second child
l was afflicted with cystic fibrosis. The court found
t the physicians could be held liable for the medical
■ enses of both children. The court held that the
I sicians had a duty to the first child and a separate
(y to the parents to advise them that their first child
ered from cystic fibrosis and to inform them of the
;s of conceiving a second child. The court also held
ft it was foreseeable that a second child could suffer
'n the disease.
1 1979, the New Jersey Supreme Court held that
sicians could be held liable for failure to inform a
year-old pregnant woman of the availability of am-
:entesis.
hysicians, particularly obstetricians should be fam-
r with standards and guidelines regarding genetic
nseling. The Genetic Services Program of the New
sey State Department of Health suggests the follow-
! indications for referral for genetic counseling:
Family history of an inherited or chromosomal
disorder, or family clustering of a disorder
Genetic disorder or congenital anomaly in a family
member
Delayed or abnormal physical and/or mental de-
velopment
Mental retardation of unknown etiology
Specific religious, ethnic, or geographic back-
ground in which certain genetic diseases are
prevalent
Drug use or chronic exposure to radiation or in-
dustrial chemical, particularly known teratogens
or mutagens
History of two or more spontaneous abortions,
stillbirths, and/or early infant deaths
Infertility
Consanguineous marriage
hese closely parallel the indicators identified by the
A Council on Scientific Affairs (Genetic Counseling
i Prevention of Birth Defects, JAMA 248:221, 1982).
'he Genetic Services Program suggests the following
ications for consideration of amniocentesis:
Maternal age 35 or older
Paternal age 45 or older
Previous child with chromosomal abnormality
Either parent a known carrier of a balanced or
unbalanced chromosomal abnormality
Previous child with a neural tube defect or signifi-
cant family history of a neural tube defect
Mother a known or presumed carrier of a serious
x-linked recessive disorder
Both parents carriers for a diagnosable autosomal
recessive disorder
ls the field of genetic counseling and prenatal
ting grows and develops greater recognition, par-
ilarly in the media, the public’s expectations ac-
dingly will increase. Failure to obtain appropriate
letic counseling no doubt will result in more law-
ts.
The rise in the rate of cesarean births has received
significant coverage in the press. See, for example, the
article entitled “Controversy Surrounds the Increasing
Number of Cesarean Deliveries,” The Wall Street
Journal , Thursday, January 19, 1984. It has been esti-
mated that one out of every five babies bom in the U.S.
this year will be delivered by cesarean and in the North-
east the figure may be as high as one in three or two
out of five. Improved anesthetic techniques, new anti-
biotics, technological developments in electronic fetal
monitoring, and the age-old dictum of “once a
cesarean, always a cesarean" all have been cited as
contributing to the increase.
Physicians can best protect
themselves by keeping
thorough records of
prenatal visits.
Obstetricians’ fear of malpractice suits also un-
doubtedly has multiplied the number of cesareans. A
patient may sue for the unnecessary performance of
a cesarean. On the other hand, a substantial number
of obstetrical malpractice cases are based on allega-
tions of failure to do a timely cesarean. The potential
damages resuking from failure to do a timely cesarean
far outweigh the potential damages for performance of
an arguably unnecessary C-section. For example, a New
Yorkjuiy awarded $3,318,000 to a plaintiff whose new-
born male infant suffers from mild cerebral palsy as
a result of traumatic vaginal delivery (Trotman v New
York Hospital N.Y. County Supreme Court, No.
9175/77, June 22, 1983). A resident who examined the
plaintiff discovered a breech presentation but did not
report it. The child was found to be in a single footling
breech presentation when the mother’s membranes
spontaneously ruptured five hours later. Diagnostic x-
ray pelvimetry was not performed. The jury agreed with
the plaintiffs that the defendants had improperly man-
aged and delivered the child by vaginal route rather
than by cesarean section. (The case was reported in 26
ATLA L. Rep. 472 December 1983.)
Inadequate monitoring and delayed cesarean section
were alleged in a suit in California (Unana v Torrance
Memorial Hospital Los Angeles Superior Court, No.
22-681, Dec. 1982). The plaintiff was admitted to the
hospital in active labor. The patient’s chart indicated
fetal heart irregularity which was shown by external
monitoring an hour after admission. The defendant
obstetrician was notified by telephone of late decelera-
tions an hour later. Two hours later “prolonged de-
celerations” were noted and again reported to the ob-
stetrician by telephone. The defendant obstetrician did
not arrive at the hospital until two hours later. A
cesarean was performed but the child sustained brain
injury resulting in severe mental and motor retarda-
tion and spastic quadriparesis. The defendants settled
for $1,100,000. (The case was reported in 26 ATLA L.
Rep. 186, May 1983.)
Gynecologic surgery resulting in unintentional in-
jury to the bladder, nerves, ureters, urethra uterus,
and bowel comprise a significant percentage of claims
>L. 81— NUMBER 8— AUGUST 1984
625
against ob-gyns. Illustrative of allegations with regard
to gynecologic surgery are the following accounts of
two recent cases reported in the American Trial Law-
yers Association Law Reporter.
In a Rhode Island case the plaintiff reached a
$215,000 settlement for the kidney and brain damage
of a 39-year-old woman whose right ureter and left
common iliac artery unintentionally were ligated dur-
ing repair surgery.
A survey by the ACOG reveals
that 60 percent of the
respondents have been sued
more than once .
The patient experienced internal bleeding following
a cesarean section performed by defendant obstetri-
cian. The physician reopened and, in an attempt to
control the bleeding, ligated the left common iliac ar-
teiy and the right ureter. The absence of a left femoral
pulse was noted upon closing. The patient was ex-
tubated and suffered respiratory and cardiac arrest.
The physician consulted a cardiovascular surgeon who
located and ligated a right internal iliac bleeder and
freed the mistakenly ligated artery. Ligation of the
right ureter was revealed by a pyelogram several weeks
following the surgery, but plaintiff required removal of
the right kidney. The patient also suffered transient
petit mal seizures for two years following the surgeiy
as a result of cerebral anoxia during the cardiac arrest.
(26 AT LA L. Rep. 42, 1983.)
A more common allegation is illustrated in the fol-
lowing account of a recent Florida case which resulted
in a $507,000 jury verdict for a 32-year-old woman who
suffered urinary tract injury during a hysterectomy.
The patient was admitted to defendant hospital for
a hysterectomy performed by defendant obstetrician.
While tying off blood vessels during the operation the
obstetrician placed sutures near one of plaintiffs
ureters. Following surgery plaintiff experienced ab-
dominal pain and was unable to eat or drink, but
hospital staff did not undertake exploratory surgery.
Surgery performed at another facility revealed that the
ureter had been blocked by defendant’s sutures, caus-
ing urine to seep into the body cavity. Plaintiff and her
husband brought suit against the obstetrician and
against the hospital, for inadequate supervision of a
patient under heavy medication. The jury awarded
plaintiffs $500,000 from the obstetrician, including
$30,000 for loss of consortium, and $7,000 from the
hospital. (26 AT LA L. Rep. 42, 1983.)
Cases alleging failure to diagnose breast cancer and
especially failure to timely diagnose breast cancer have
and will continue to plague physicians. The prolifera-
tion of breast cancer cases may stem in part from the
concept that early detection is early cure. The public
has come to believe, with a degree of faith akin to
religious belief, that routine and early screening for
breast cancer, significantly will improve survivability.
As a result of a recent breast cancer case decided by
the Supreme Court of New Jersey, 95 N.J. 399, 1984,
breast cancer cases may be increasingly difficult to
defend. The legal issue in that case focused on tl
issue of “causation.” The case involved the followir
scenario. A young woman presented to her physicia
with a small painful lump in her right breast. After a
examination, the physician told her it was “nothing 1
worry about.” Seven months later, the plaintiff r
turned with complaints of continued pain, an increae
in the size of the lump, and a “sore” with some bleedir
in the area Culture results proved “negative for infe>
tion.” The patient sought an opinion from anothr
physician. The patient underwent a right extensn
mastectomy. A pathologist diagnosed infiltrating du<
tal carcinoma of the right breast. Subsequently, it wa
determined that the cancer had metastasized to tL
lung, rendering the patient’s prognosis for recover
poor.
The patient sued the physician alleging failure 1
diagnose the cancer. She contended that the delay i
diagnosis increased the risk of metastasis and cons<
quently deprived her of a chance of long-term survive
The case ultimately reached the New Jersey Suprenr
Court. It held that a plaintiff should be permitted t
demonstrate, within a reasonable degree of medic;
probability, that the delay resulting from the defendar
physician’s failure to render an accurate diagnosis an
treatment increased the risk of metastasis and the
such increased risk was a substantial factor in produc1
ing the condition from which the plaintiff suffers.
The court also held that the plaintiff need not qualit
the magnitude of the increased risk. Once the plainti
has shown that the defendant’s negligent act or omis!
sion increased the risk of harm to the plaintiff, thejur
will be permitted to decide whether or not the ir
creased risk was a substantial factor in producing th
resultant harm. The court also ruled that the plainti
would recover damages for mental and emotional ir
jury resulting from the negligent failure to time
diagnose and treat the tumor.
As a result of the decision in this case, it is like)
that juries will award larger monetary damages tha
they would have in the past for cases such as thes<
RISK REDUCTION
The Department of Risk Prevention of the Media
Inter-Insurance Exchange of New Jersey recently corr
piled a statistical analysis of 223 ob/gyn claims ill
which a total of $15,896,752 was paid. A few of th
major categories of losses are presented below.
Eleven claims stemming from allegations of failur
to diagnose breast cancer resulted in payment tj
claimants totalling $1,717,000. Delay in obtaining
biopsy or failure to biopsy were common allegations iij
these cases. Breast cancer cases represent the larges
gyn loss. Such cases can have a devastating impac
where the plaintiff can demonstrate a diminished lif
expectancy.
Five claims alleging failure to diagnose and respom
to fetal distress resulted in payments to claimant:
totalling $2,204,830. Where the infant suffers braii
damage, the physician may be held liable for the cos
of long-term institutional care.
Thirty-three claims involving alleged improper per
formance of procedures such as tubal ligations, hys
terectomies, abortions, and assisted deliveries resultec
626
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
payments totalling $1,459,602.
Gynecological surgery cases causing injury to the
itient resulted in payments of $849,327.
INCLUSION
Medical malpractice liability is clearly expanding in
e area of obstetrics and gynecology. This is partly a
suit of legal recognition of new theories of liability
id expanded areas for the award of damages.
Physicians who continue to practice in this high-
>k specialty can best protect themselves by keeping
orough records of prenatal visits and other care
ovided. Conclusions should be well documented with
pporting reasons.
Where fetal monitoring and other technology is used.
the physician should be mindful that hospital person-
nel may not be as skilled as the physician would wish
with regard to the use and interpretation of the data
generated. Electronic fetal monitoring should never be
a substitute for the exercise of the physician’s clinical
judgment. Physicians should encourage hospitals to
store and make readily retrievable, all tracings of fetal
monitors. In some cases the fetal monitor tracings may
represent the only documentary evidence of fetal non-
distress.
Ob-gyns also should avail themselves of the technical
bulletins published by the American College of Ob-
stetricians and Gynecologists. These bulletins have be-
come “must” reading for plaintiffs’ attorneys. No less
can be expected of the practitioner.
L. 81— NUMBER 8— AUGUST 1984
627
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628
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER :
!
ROFESSIONAL LIABILITY
OMMENTARY* *
The Effects of
Malpractice
Effects of Malpractice; Informed Consent;
nformal Consultations
Sara C. Charles, M.D., recently
had completed a survey of Chi-
cago area physicians who have
en sued for medical malpractice. Dr. Charles ran-
imly selected 154 Chicago physicians who had suits
ed against them between 1977 to 1981.
Some of Dr. Charles’ findings as reported in the April
sue of the Medical Liability Monitor are:
• Most physicians (89.6 percent) felt that the plain-
fs suit was unjustified, 44 percent resented efforts
' insurance and legal counsel to settle the case, and
) percent felt that settling the case was tantamount
admitting guilt.
• More than half (54.5 percent) felt that litigation is
irt of practicing medicine today and not an affront
one’s competence, but 88 percent reported feeling
lger— mild to severe— over being sued.
• Almost 70 percent of those surveyed said they kept
ore meticulous records after being sued, but 25 per-
nt said they recorded less “pertinent” information in
cords.
• Most of the physicians (62 percent) said they or-
'red diagnostic tests for “protection” even when
inical judgment assessed these as “unnecessary.”
j* Some 28 percent of the doctors stopped per-
rming certain high-risk procedures while 42 percent
opped seeing “certain kinds” of patients.
• Twenty-five or 18.8 percent of the respondents felt
“loss of nerve in some clinical situations” and 14
:rcent said they felt less self-confidence as a physi-
an after being sued.
• More than half of the physicians (56.6 percent) felt
that they and their families had suffered as a result
of the suit, while 19 percent felt that their medical
practice had suffered. One-third or 33.6 percent of the
doctors thought about early retirement after being
sued.
In surveying physicians for symptoms, Dr. Charles
had to rely on self-reports since no personal interviews
were carried out. But even on paper, two clusters of
symptoms emerged: “Of the 143 physicians who
assessed themselves for symptoms, 39 percent ad-
mitted to four or five symptoms which suggested a
possible major depressive disorder; and another 20
percent acknowledged another group of symptoms, in-
cluding anger, change in mood, inner tension, frus-
tration, irritability, insomnia, fatigue, and headache.
Eleven of the physicians (8 percent) noted the onset
of a physical illness during litigation, while 3 physi-
cians had a coronary during the process. Almost 8
percent of the doctors reported aggravation of a
previously diagnosed illness. Only 4 percent of the
physicians said they had no physical or emotional
symptoms associated with the malpractice litigation.”
(Medical Liability Monitor, Vol. 9, No. 4, April 30, 1984)
MORE ON INFORMED CONSENT
As if hospitals don’t have a big enough hand in your
affairs already, they may soon be checking up on how
well you have obtained informed consent. In what
could be a significant case, an Illinois doctor and hos-
pital both will stand trial on the charge of failing to
inform a patient of the risks of a surgical procedure.
In the past, hospitals routinely have been dismissed
from such cases, but this time an appeals court okayed
a trial. If the case establishes a precedent, hospitals
could be forced to ensure that you have truly informed
the patient of the risks involved, and not just obtained
his signature on a form. ( Medical Economics, March
19, 1984)
LIABILITY FOR INFORMAL CONSULTATION
When an acquaintance asks a physician about his
jogger’s knee or tennis elbow at an informal gathering,
the physician could be held liable for his opinion.
According to the “Practice Management” in the
March issue of Medical Economics, “By giving an
opinion, even in an informal setting, you could be es-
tablishing a physician-patient relationship and as-
suming responsibility for the person’s care. Also, your
“curbside” opinion might persuade your questioner
not to get a proper diagnosis and treatment. If this led
to complications, you could be liable. So when an ac-
quaintance asks you for an informal opinion, it is best
to either say you would like to be helpful but cannot
diagnose his problem without examining him and
doing the necessary tests, or advise him to consult a
specialist if the problem is out of your field. (Medical
Economics, March 19, 1984)
*This item from the Department of Professional Liability Con-
trol, MSNJ, was prepared by James E. George, M.D.. J.D., and
A. Ronald Rouse who are, respectively, Director of the Depart-
ment and Director of Special Projects.
3L. 81— NUMBER 8— AUGUST 1984
629
1
■ ' " " " — ■ 1 ^
FIFTH ANNUAL MEDICOLEGAL SEMINAR
Wednesday, September 12, 1984
8:30 a.m.- 4:00 p.m.
Medical Society of New Jersey Executive Offices
Two Princess Road
Lawrenceville, NJ 08648
presented by
■ \
Medical Inter-Insurance
Exchange of New Jersey
Department of Risk Management
Afternoon Session
12:00 Lunch
12:45 “Medical Malpractice; The
View from the Chair”
James S. Todd, M.D.
Chairman, Board of MIIENJ
1:00 “The Professional Liability
World Today; The State of
the Industry”
Peter Sweetland, President,
MIIENJ
1:45 “The Claim Climate in New
Jersey; A History and a
Look at the Future”
Joseph DeRoma, Vice-President,
Claims, MIIENJ
2:30 “An Ounce of Prevention;
Causes of Suits and Programs
Developed To Avoid Them”
Adam P. Wilczek, Director,
Department of Risk Management,
MIIENJ
3:15 Questions and Answers
APPROVED FOR 5V2 CME CATEGORY I CREDITS
REGISTRATION
PLEASE RESPOND NO LATER THAN AUGUST 31, 1984
NO REFUNDS AFTER SEPTEMBER 10, 1984
MSNJ MEMBER OR MIIENJ INSURED $10.00
NON MSNJ MEMBER OR 25.00
NOT INSURED WITH MIIENJ
Medical Society of New Jersey
Department of Professional
Liability Control
Morning Session
8:30 Registration and Coffee
9:00 Greetings
Frank Y. Watson, M.D., President,
MSNJ and James S. Todd, M.D.,
Chairman of the Board, MIIENJ
9:20 Opening Remarks
James E. George, M.D., J.D.,
Director, Department of Professional
Liability Control
9:45 “The Snitch Bills; Their Impact
on Medical Malpractice”
Vincent A. Maressa,
Executive Director, MSNJ
10:15 “Reporting of Medical Malpractice To
State Board of Medical Examiners”
Floyd J. Donahue, M.D., Member of State
Board of Medical Examiners
10:45 “The New Case Management and
Procedures of Malpractice Litigation”
Honorable Peter Ciolino, Assignment Judge
Superior Court, Passaic County
11:15 Questions and Answers
DETACH AND MAIL TO MSNJ, TWO PRINCESS ROAD, LAWRENCEVILLE, NJ 08648
Enclosed is my check for payable to MSNJ
NAME (PLEASE PRINT)
ADDRESS
PHONE #
A CONFIRMATION WILL BE SENT TO YOU ALONG WITH DIRECTIONS TO MSNJ.
630
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
ditorial
The Challenge of the
Geriatric Imperative
Michael A. Nevins, m.d.*
Can community hospitals meet the
challenge of the geriatric imperative? A
workshop sponsored by the New Jersey
Chapter of the American College of
Physicians studied the question.**
How appropriate it is that since
their births at the beginning of
the century, the codisciplines of
iriatries and gerontology have taken the equivalent
a full human life span before entering into their
ilden age. The frenetic pace of events during the past
:cade attests to an emerging awareness of the
mensions of what Anne Somers so eloquently has
laracterized as “the geriatric imperative.”
Much attention has been focused on organizational
insiderations (e.g. whose speciality is it?) and at de-
:loping and introducing curriculum at all levels of
edical education. Whereas teaching hospitals and
edical schools have begun to meet the challenge of
he new geriatrics,” there is little evidence that the
ition’s smaller community hospitals have been re-
>onding comparably. This is alarming since it is dif-
:ult to envision an efficient health delivery system for
ie elderly in which community hospitals do not play
central role. Indeed, it is at these institutions where
ost primary care for seriously ill, older people is
'ovided. Increasingly, the constituency of community
)spitals is composed of Medicare patients with be-
/een one-third and one-half of admissions and total
ispital days currently being devoted to their care.
In pre-World War II England, Marjorie Warren ap-
eciated that conventional care of the elderly by inte-
ntion into general hospital wards, often was anti-
letical to recovery. As a result, discrete geriatric wards
nerged early in Great Britain and later in many other
>untries in Europe and Canada. For example, in 1981,
of Israel’s 28 general hospitals had acute geriatric
ards designed to care for those patients who are more
fictionally impaired than their independent col-
leagues of similar advanced age. Although it is difficult
to extrapolate results from countries which operate
under nationalized systems to our needs, it is surpris-
ing that relatively little attention has been paid in the
United States to how the aged are treated within our
acute hospitals. Rather, most current attention is
being directed at nursing home care, home care, and
methods of keeping patients out of hospitals
altogether. Although this is commendable, it is un-
realistic to presume that the nation’s elderly will not
continue to occupy a substantial, if not increased,
proportion of acute beds in community hospitals. This
particularly is the case in New Jersey which in the
United States ranks only after Florida in average age
of the population.
If the 1970s represented the renaissance of
geriatrics, the 1 980s and beyond likely will be a period
of challenge and opportunity when implementation of
many of the lessons of the past decade will be tested
for efficacy, practicality, and cost effectiveness. It has
become fashionable to revere “the team” as the
geriatrics equivalent of high technology. Whether the
team concept can be made to work is a crucial question
since internists and family physicians, who have
tended to work best as solo virtuosi, would have to be
remolded into conductors. Medical and nursing
schools now are producing a new generation of young
geriatricians who will have a fresh perspective on car-
ing for the elderly. Will community hospitals be
prepared to receive them and have programs in place
to best utilize their talents?
Our workshop provided an opportunity to address
one component of the broad spectrum of issues that
comprise the current geriatric agenda It is quite ap-
propriate that the American College of Physicians
should sponsor this study since in its long and dis-
tinguished history the College consistently has played
a central role in supporting innovation and has
provided leadership in matters pertaining to excellence
of medical care. It is my hope that, as a result of our
deliberations, we will be able to identify those factors
which constitute good contemporary practice of hospi-
tal geriatrics. The series of articles in this issue high-
light the discussions from the workshop.
*Dr. Nevins is Governor, New Jersey Chapter, American Col-
lege of Physicians. Correspondence may be addressed to Dr.
Nevins. 595 Chestnut Ridge Road. Woodcliff Dike, NJ 07675.
“The workshop was held on May 5, 1983, at MSNJ head-
quarters, Lawrenceville, and was sponsored by the New Jersey
Chapter of the American College of Physicians.
3L. 81— NUMBER 8— AUGUST 1984
631
Editorial
Eye Health
Screening Week
Alfonse A. Cinotti, m.d.
Eye Health Screening Week will begin
September 17, 1984, in 88 New Jersey
hospitals. The program is free and
readily available.
For the 28th consecutive year, the
Medical Society of New Jersey
will conduct an eye health
screening program in 88 hospitals during the week of
September 17, 1984, with the cooperation of the New
Jersey Academy of Ophthalmology and Otolaryngology,
the New Jersey Hospital Association, the New Jersey
State Department of Health, the New Jersey State Com-
mission for the Blind and Visually Impaired, the Na-
tional Society to Prevent Blindness-New Jersey, and
the Lions Club of New Jersey.
Since this program began, over 250,000 people have
been screened. There have been a significant number
of positive findings including: glaucoma, cataracts,
various types of retinopathy, and eye tumors.
Perhaps the greatest impact in sight conservation
has been the finding of 3,000 new cases of glaucoma
Since glaucoma is one of the major causes of prevent-
able blindness, early diagnosis permits sight-saving
treatment.
In this screening, tests for two of the earliest signs
of glaucoma — increased intraocular pressure and pro-
gressive cupping of the optic nerve— are performed.
Although this program is free and effective, only a
small percentage of the public has taken advantage of
the screening. We believe that the program should be
expanded. The MSNJ Conservation of Vision Commit-
tee, along with other organizations, reviews the project
annually in order to determine ways of increasing par-
ticipation. The Committee especially is concerned with
the program’s failure to make a greater impact in |
inner cities, where the incidence of glaucoma is higf;
and the loss of vision is greater.
There is no question that the MSNJ Eye Heal
Screening Program has made valuable contributil
by promoting knowledge and understanding of eye <ii
eases and the need for periodic eye examinations
Eveiy physician can aid in screening for glaucoma
by a careful ophthalmoscopic evaluation of the oj <3
disc, especially in those patients who are at great
risk: senior citizens, those with family historic
glaucoma, and the black population.
The normal optic nerve has clear margins, p
color, and a physiological cup, which generally is
than .3 of the diameter of the disc, both vertically
horizontally. The cup in both eyes usually is simij
The examiner should refer patients who have lal
cups, especially where there is a disparity between |
two eyes, where the vertical cup is larger, whjji
notching appears in the rim, where the vessels sli
marked deviation, or where hemorrhages are seen
the disc. It has been established that changes in
optic disc generally occur before demonstrable vi;
field changes. i
Given the benefits of early diagnosis, we encourJ
physicians to pay special attention to the optic ne|
and to remind their patients of the need for periojc
eye examinations. The Eye Screening Program is f
and readily available.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS/
632
BALANCED
CALCIUM
BJ
dw incidence of side
mDIZEM® (diltiazem HC1)
uduces an. incidence of adverse
{actions not greater than that
{ported with placebo therapy,
lus contributing to the patient’s
jnse of well-being.
iizem is indicated in the treatment of angina pectoris due to
)naiy artery spasm and in the management of chronic stable
ina (classic effort-associated angina) in patients who cannot
rate therapy with beta-blockers and/or nitrates or who remain
lptomatic despite adequate doses of these agents.
irences:
Reduces angina attack frequency
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test,2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (PC.005).
CARDIZEM
rauss WE, McIntyre KM, Parisi AE, et al: Safety and efficacy
f diltiazem hydrochloride for the treatment of stable angina
actoris: Report of a cooperative clinical trial. Am J Cardiol
9:560-566, 1982.
ool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise-
liducible chronic stable angina with diltiazem: Effect on treadmill
xercise. Chest 78 (July suppl):234-238, 1980.
(diiUazem HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
2/84
Please see full prescribing information on following page.
PROFESSIONAL USE INFORMATION
cardizem,
(dilhazem HCI)
30 mg and 60 mg tablets
DESCRIPTION
CARDIZEM* (diltiazem hydrochloride) is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist). Chemically,
diltiazem hydrochloride is 1 ,5- Benzothi azepi n-4(5H )one ,3-(acety I oxy)
-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride,(+) -cis-.The chemical structure is:
CH2CH2N(CH3)2
Diltiazem hydrochloride is a white to oft-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform
It has a molecular weight ot 450.98 Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administration.
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle.
Mechanisms ot Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovme-induced cor-
onary artery spasm are inhibited by CARDIZEM.
2. Exertionai Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads.
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect. The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases in peripheral resistance.
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrioventricu-
lar conduction in isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate-blood pressure product for any given work load.
Studies to date, primarily in patients with good ventricular function,
have not revealed evidence of a negative inotropic effect; cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
of diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater than first-degree
AV block. Diltiazem-associated prolongation of the AH interval is not
more pronounced in patients with first-degree heart block. In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine. In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins. Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxm, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration. The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours. Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem. Therapeutic blood levels of
CARDIZEM appear to be in the range of 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given; a 120-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem.
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment of spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM has been effective in controlled trials In
reducing angina frequency and increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a functioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1 . Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome. This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0.48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2 Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited. Caution should
be exercised when using the drug in such patients.
3 Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4 Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued In dogs,
doses of 20 mg/kg were also associated with hepatic changes;
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated. Available data are not sufficient, however, to predict
the effects of concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21 -month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests. No intrinsic effect on fertility was observed
in rats.
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women, therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded.
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition. In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are: edema (2.4%),
headache (2.1%), nausea (1.9%), dizziness (1.5%), ,|
asthenia (1.2%), AV block (1.1%). In addition, the foil m
were reported infrequently (less than 1%) with the orde 1
tion corresponding to the relative frequency of occurn ;
Cardiovascular: Flushing, arrhythmia, hypotensi i
Nervous System
Gastrointestinal:
Dermatologic:
Other:
i t» 1
dia, palpitations, congestive M ,
syncope.
Paresthesia, nervousness, » ;
tremor, insomnia, hallucinations, g
Constipation, dyspepsia, diarrhi u
mild elevations of alkaline phospL g
SGPT, and LDH.
Pruritus, petechiae, urticaria, phc e
Polyuria, nocturia.
The following additional experiences have been not
A patient with Prinzmetal's angina experiencing
vasospastic angina developed periods of transient ali
asystole approximately five hours after receiving a s |B
dose of CARDIZEM
The following postmarketing events have been re al -
quently in patients receiving CARDIZEM: erythema mu mi
kopenia, and extreme elevations of alkaline phospha ?
SGPT, LDH, and CPK However, a definitive cause and ef «
these events and CARDIZEM therapy is yet to be esta fl
OVERDOSAGE OR EXAGGERATED RESPOil
Overdosage experience with oral diltiazem has b
Single oral doses of 300 mg of CARDIZEM have been * :
by healthy volunteers. In the event of overdosage or j
response, appropriate supportive measures should be i
addition to gastric lavage. The following measures may beu<
Bradycardia
Administer atropine (0.60 to 1.0 I
is no response to vagal blockade li
High-Degree AV
Block
isoproterenol cautiously.
Treat as for bradycardia above.
Cardiac Failure
Hypotension
degree AV block should be treatir"
diac pacing.
Administer inotropic agents (isc tci ^
dopamine, or dobutamine) and diu n
Vasopressors (eg, dopamine or I m
bitartrate).
Actual treatment and dosage should depend on the se :u |
clinical situation and the judgment and experience of jet
physician
The oral/LD50's in mice and rats range from 415 to it
and from 560 to 810 mg/kg, respectively. The intravenoi 0.
these species were 60 and 38 mg/kg, respectively. The it
dogs is considered to be in excess of 50 mg/kg, while lf;it»<
seen in monkeys at 360 mg/kg. The toxic dose in man is l xn:
but blood levels in excess of 800 ng/ml have not been g|
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atheroscler i
nary Artery Disease or Angina Pectoris at Rest Du (X
nary Artery Spasm. Dosage must be adjusted to eac itf
needs. Starting with 30 mg four times daily, before me,al
bedtime, dosage should be increased gradually (given ft
doses three or four times daily) at one- to two-day intrie
optimum response is obtained Although individual pa si
respond to any dosage level, the average optimum do; ra
appears to be 180 to 240 mg/day. There are no available da fflt
ing dosage requirements in patients with impaired renal 8
function. If the drug must be used in such patients, titratioi 'rt
carried out with particular caution.
Concomitant Use With Other Antianginal Agent!
1 . Sublingual NTG may be taken as required to a a
anginal attacks during CARDIZEM therapy.
2 Prophylactic Nitrate Therapy -CARDIZEM may
coadministered with short- and long-acting nitrates
have been no controlled studies to evaluate the :|
effectiveness of this combination.
3 Beta-blockers. (See WARNINGS and PRECAUTION!
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles of I
0088-1771-47) and in Unit Dose Identification Paks of il
0088-1771-49). Each green tablet is engraved with MARK «
side and 1771 engraved on the other. CARDIZEM 60-n c
tablets are supplied in bottles of 100 (NDC 0088-1772-47)
Dose Identification Paks of 100 (NDC 0088-1772-49). E; '
tablet is engraved with MARION on one side and 1772 on
Issue,
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES. INC
KANSAS CITY, MISSOURI 64137
nspiTAL Governing
E)ARDS*
Government Mandated
*eer Review —
delegation to Hospital
/INCENT A. MARESSA, J.D.
Tie Department of Health and Human
Services is required to contract with
[ualified peer review organizations
PROs ) to provide peer review of Medi-
care and Medicaid claims.
In enacting P.L. 97-248, the Tax
Equity and Fiscal Responsibility
Act of 1 982, Congress inserted a
5 tion known as the Peer Review Improvement Act of
1 32. By this statute, the Department of Health and
liman Services is required to contract with qualified
fpr review organizations (PROs) to provide peer re-
|w of Medicare and Medicaid claims, and to deny
pyment for services found to be unnecessary.
The basic thrust of the legislation is to control ad-
i ssions and utilization. It is believed that in this
f hion Medicare and Medicaid will become cost effec-
t e. PSROs will be phased out and replaced by state-
i de PROs. Health care facilities specifically are ex-
: ided from acting as PROs. The PROs, however, are
: thorized to subcontract some or all of the functions
t hospitals without running afoul of the statutory
£ :lusion. Ultimate responsibility for the review activi-
! must remain within the PRO.
The ability to delegate review to hospital committees
i limited somewhat in New Jersey since the state gov-
£ mient, through the Division of Medical Assistance,
partment of Human Services, will not permit del-
egation for Medicaid cases. State law does permit del-
egation under the DRG program for all non-Medicaid
reviews.
While federal law is phasing out PSROs as such, it
has replaced them with a PRO of statewide signifi-
cance. This is an interesting turnabout. When the
PSRO legislation originally was being considered. Con-
gress determined that PSROs should function on less
than a statewide basis, even though the medical pro-
fession advised that a single statewide organization
would assure quality, consistency, and economy in the
review process. Today, Congress has ruled “statewide”
is better.
Regardless of the format, delegation as such is of
vital importance to our physicians and hospitals, and
the presently forming PRO in New Jersey must be en-
couraged to make maximum use of responsible del-
egation.
‘The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, M.D.,
Executive Director, MSNJ; and James E. George, M.D., J.D.,
Director of Professional Liability, MSNJ.
L. 81— NUMBER 8— AUGUST 1984
635
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Name MSNJ Member
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BlueCros:
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□ Major Medical Program
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Return to:
Donald F. Smith & Associates
One Airport Place, Route 206 North
P.O. Box 2197,
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(609) 924-8700, (201) 622-6046
636
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
yRIATRIC IMPERATIVE: SHOULD COMMUNITY
jspitals Have Geriatric Units?
:hael A. Nevins, m.d., woodcliff lake*
ie modem hospital can be a hostile environment for the frail
derly. A potential solution to this problem is to develop special
ire units designed to being sensitive to patients9 unique needs ,
minimize the hazards of hospitalization, and to maintain
'neralfunction as acute illness is being treated .
Between 30 and 50 percent of all
acute hospital beds currently
are occupied by patients over
>5. Not only do older patients have dispropor-
tely more hospital admissions, but their duration
~ost of stay substantially are greater than that of
ger groups. In assessing contemporary hospital
trie care, neither unqualified endorsement or in-
lent would seem to be appropriate. Perhaps it
d be best to begin by considering whether our
tiling system in this country, in which all acutely
itients spatially are integrated, works optimally
of the time.
course, age, per se, should not be the issue since
r persons of even far advanced age retain their
al and physical faculties so that they are quite
rendent and need not be treated differently. The
tional definition of geriatrics as over 65 is arbi-
and inadequate, there being little that dis-
lishes special needs of the decade beyond 65 from
just before it. After age 75, however, health and
losocial problems begin to accelerate and com-
d to the extent that many of the advanced elderly
to arrive at a symbiotic relationship with their
lie infirmities, the event that causes acute hospi-
ition being but the last of a series of setbacks,
jfore, function rather than age should be the
al determinant that characterizes the geriatric
nt.
The acutely ill geriatric patients typically have
diminished physiologic reserve and decreased capacity
to adapt to unfamiliar surroundings which puts them
at increased risk of complications. As a result, the
modem hospital with its disease orientation and fixed
methodology often is a hostile environment for the frail
elderly. Early studies suggested that the complication
rate on general medical wards was twice as great for
patients over age 70 and that nearly 40 percent en-
counter iatrogenic problems such as reactions to
medications or procedures, accidental trauma, hospi-
tal-related psychologic decompensation, or nosocomial
infection.1 A recent study of 279 patients age 70 or
more at a 400-bed community hospital found con-
siderable age-related disability with more than half of
those 75 years or older needing activities of daily living
(ADL) assistance, about two-fifths receiving psy-
chotropic medications, and one-fifth incontinent and
in need of catheters.2 Over age 85, 54 percent were
moderately or severely disoriented, 34 percent had im-
paired hearing, 40 percent had impaired vision, and
25 percent had a speech impairment.
Is it any wonder that already overburdened nursing
staffs often are frustrated and hard pressed to attend
to the added needs of many elderly patients and ex-
press the need for additional help? The present hospi-
*Dr. Nevins is Governor, New Jersey Chapter, American Col-
lege of Physicians.
81 -NUMBER 8 — AUGUST 1984
637
tal system, however, responds poorly to this need; a
common response is to distribute the oldest patients
around so as, at least, to share the extra work
equitably.
One potential solution to this universal problem is
to develop special care units for certain categories of
the elderly; in such units, sensitivity to the patients’
needs might minimize the hazards of hospitalization
and maintain general function even as acute illness is
being treated. Although conceptually this is an attrac-
tive idea, there are distinct pitfalls to successful im-
plementation. Many instructive models are available
from which to learn, notably from Great Britain, Can-
ada Europe, and Israel where geriatrics units are com-
mon. Recently, several centers in the United States
have developed.
In this country, most innovations in geriatrics have
occurred in larger teaching hospitals, one variety being
the roving team approach where small multi-
disciplinary groups seek out patients on conventional
wards to provide consultative and educational ser-
vices.3 Geriatrics units which are directly responsible
for inpatient care essentially can be considered as one
of the following two basic models:
1. Postacute Care. Patients are accepted into the
geriatric unit only after acute illness has been
stabilized, the major emphasis being on rehabilitation
and avoidance of long-term institutionalization. One
example at the Sepulveda, California VA Hospital that
is proving to be “cost effective” was described by
Rubenstein.4 Lefton et al. also have found that overall
function of elderly patients was improved when treated
on a multidisciplinary geriatric unit, weeks to months
after a catastrophic acute illness.5 The determination
of unit effectiveness depends substantially on the
selection of patients and their premorbid functional
status. In this respect, the ideal candidate would be
one who was reasonably well before developing an
acute illness, such as a stroke, who after concentrated
rehabilitative effort is able to return home.
2. Day-One Units. These provide all the services of
any conventional acute medical-surgical unit but may
have different orientation, operating policies, and staff-
ing patterns. Patient demography, of course, varies
with the local ground rules. At Shaare Zedek Medical
Center, Jerusalem, where admissions are at the discre-
tion of the resident staff and according to bed avail-
ability, those patients admitted to acute geriatrics
rather than general medicine tend to be more func-
tionally disabled in regard to mobility, mental state,
and continence.6
In this country an outstanding example of com-
prehensive geriatric care at a 200-bed community hos-
pital is the unit developed by Albert A Fisk, M.D., at
the Wisconsin Regional Geriatric Center, Milwaukee.7
In a personal communication, Fisk noted that his orig-
inal conception for a geriatric unit primarily was from
an educational benefit point of view, but as time went
on it became apparent that the unit had a great deal
more value:
“When an elderly patient is hospitalized, the medical
problem is most likely to be just the tip of the iceberg
and a host of psychosocial problems frequently accom-
pany the acute medical problem. Developing a team to
address these different problems, therefore, is the
major object in developing an acute care geriatric u
This is not at all easy. Over a period of two year;y
developed a very excellent team with a group of nu i
who were interested in and proud to be involve'
geriatrics. They developed some protocols for probl t
such as decubiti and constipation. The hospital lies
the model of primary care nursing which seems 1 1
in very well with the needs of our patients. Howi 3
one needs increased staffing and it particularly is c
visable to have aides available to assist in the cai <
some total care patients.” Fundamental to the sues
of the Wisconsin unit are weekly conferences which n
attended by the primaiy care nurses, the unit sej
worker, rehabilitation therapists, house staff and u
dents, pharmacists, social workers, and outpatient k
home care nurses. Communication at this ml;
disciplinary conference is open, information is sha'd
and decisions are arrived at mutually with the p;
sicians contributing to, but not dominating, the dn-
ference.
A potential solution is to
develop special care units
designed to being sensitive
to apatienVs unique needs.
Another excellent “day-one” program is that of ; e
University of Massachusetts Medical Schd,
Worcester, where the Geriatric Care Unit directed)’
Roger B. Hickler, M.D., provides a continuum of in- < ■
outpatient services including a 14-bed geriatric t it
(4 percent of the total hospital beds), an outpatht
clinic, and a community consultation and education
resource team.8 Potential admissions are screened y
staff members to avoid purely disposition proble m
but there are no other diagnostic exclusions; a r
three days, all patients are reviewed to evaluate e
appropriateness of their remaining on the ul
Special consideration is given to the frail elderly of 5
years and older with a multitude of health problesj
and to the 25 percent of patients who have some fc i
of dementia The average length of stay for the first ti
admissions over an 18-month period was 11.5 ds
and in each 5-year age group up to age 90 the lenj
of hospitalization was equal to or shorter than tha f
the corresponding age group in the remainder of e
hospital.
It is difficult to enumerate the requisite compone s
of a successful geriatrics unit. Much depends upon e
nature of the institution and the extent of its comn -
ment. Nonetheless, whether conceived as a postac e
or a day-one unit, the following comments are releva i
1. The traditional role of the primaiy care physicJ
should be preserved, but a delicate balance must 8
achieved whereby the unit staff attains sufficid
autonomy to feel that they are valued participants 1
the decision-making process. In this regard, the r'S
of the unit director can be crucial not only as i:8
gatekeeper who assures that the unit does not eves
into a disposition unit, but as a harmonizer who s<s
that the integrity of unit policies is maintained.
638
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSf
Only to the extent that the nurse and support
; are professionally gratified can initial enthusiasm
sustained and "bum-out” avoided. The geriatric
is an example of "software" (people and policy)
! g more important than “hardware” (special equip-
<t).
Although relatively little special equipment is
: ssary, some geriatric units have pioneered in de-
eping a therapeutic environment where wheelchairs
i restraints are uncommon and which serve to
iince patient orientation, encourage activity, and
■note independence.910
Implicit to optimum geriatric care is an increased
lortion of helpers to patients as compared to usual
i mg ratios. Advantage often can be taken of non-
essionals, volunteers, and family in some roles.
; imitted full-time therapists and social workers can
;c more efficiently in a special unit and satellite
: rties can obviate transport to distant parts of the
: )ital.
.< In parallel to treatment directed against the ad-
ding problem should be functional assessment so
ot to lose ground early during the hospitalization.
' rts at rehabilitation should commence as soon as
feasible. The causes of common problems such as
1 decubiti, and incontinence should be sought, but
s ng and treatment initiated only if one can reason-
> expect a beneficial functional response.
<j The geriatric unit requires a cadre of skilled pro-
■ onals who collectively may have a positive effect
i heir colleagues, not only by relieving them of per-
iod burdensome patients, but by their infectious
i usiasm and example. Also, the unit staff can serve
resource group for intramural consultation and
I ation.
’ The community hospital has the personnel, ex-
se, and support services to be the principal
< ider and coordinator of a broad spectrum of ser-
if; and is the natural focal point for community
: ities that too often are fragmented. In order for
i t-term hospital benefits to be sustained, it is
■ ssary to have a followup mechanism such as a
liitric outpatient clinic. Other modules of a corn-
tensive and integrated program might include
ti|i services as a day hospital, day-care, or respite-
j
chough many of the advantages herein described
I I be accomplished in the context of a “geriatrics
i ce-without-walls,” the likelihood of success is
i tnced if the unit has a specific place where equip-
6|t and personnel efficiently can be concentrated
|
and nurses have primary care responsibility. Ultimate-
ly, the crucial element is people: without a staff that
is affirmative, optimistic, innovative, and profes-
sionally fulfilled, a geriatric unit is unlikely to achieve
its full potential.
Finally, it should be noted that progress and
dialogue in this field have been inhibited to an extent
by several perceptions that have made geriatrics units
a "bogeyman” of sorts. Some skeptics have viewed
geriatrics units as potential repositories for the ter-
minally ill or for disposition cases. No doubt, some
internists and family -practitioners feel threatened by
the emergence of a new breed of geriatricians as still
another incursion on their turf. Nursing adminis-
trators have expressed concern about motivating their
staffs to work in areas which traditionally have been
considered to be frustrating and professionally un-
rewarding. Hospital administrators, in turn, under-
standably are cautious about initiating potentially ex-
pensive and unproved new projects in an era of in-
creased financial regulation and cost containment. All
of these legitimate concerns must be addressed if the
future practice of hospital geriatrics is to change ap-
preciably. Nonetheless, change it must.
The ubiquitous presence on general medical wards
of confused, elderly patients, posed in “geny-ehairs”
and positioned in the midst of nurses’ stations for
direct observation serves as a haunting and compel-
ling example of the bankruptcy of our present system
and the need for taking a fresh look at certain long-
standing traditions of hospital care.
REFERENCES
1. Reichel W: Complications in the care of 500 elderly hos-
pitalized patients. J Am Geriatr Soc 13:973, 1965.
2. Warshaw GA Moore JT, Friedman W, Currie CT, Kennie
DC, Kane WJ, Mears PA Functional disability in the hospital-
ized elderly. JAMA 248:847-850, 1982.
3. Blumenfield S, Morris J, Sherman FT: The geriatric team
in the acute care hospital. JAm Geriatr Soc 30:660-664, 1982.
4. Rubenstein LZ, Abrass IB, Kane RL: Improved care for
patients on a new geriatrics evaluation unit. JAm Geriatr Soc
29:531-536, 1981.
5. Lefton E, Bonstelle S, Frengley JD: Success with an inpa-
tient geriatric unit. J Am Geriatr Soc 31:149-155, 1983.
6. Greenberg NS, Rosin AJ: Factors influencing admissions
or nonadmissions of the aged to the hospital. J Am Geriatr
Soc 30:635-641, 1982.
7. Fisk AA Comprehensive health care for the elderly.
JAMA 249:230-236, 1983.
8. Hickler RB: Personal communication, 1983.
9. Gundby P: Gerontology unit focuses on mobility, not
restraint. JAMA 249:1249-1250, 1983.
10. Cape RDT: Personal communication, 1983.
81— NUMBER 8— AUGUST 1984
639
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets—
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congest
heart failure, sinus bradycardia, cardiogenic shock, heart block great
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING mg
CAPSULES
, ' The appearance of
INDERAL LA
capsules is a registered
trademark of
Ayerst Laboratories,
I
ONCE-DAILY
jUST ONCE EACH DAY
FOR SIMPLIFIED CORE ,
THERAPY IN ANGINA (PROPRANOLOL HCI)
InderalLA IIS
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL" LA brand ol propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80, 120. and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60%'to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output. (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum pggggpum concentration when used, in the
treatment of hypertensive patients.
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced increases in the heart rate,
systolic blood pressure, and the velocity and extent of mydbardtal contraction Prop|anolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic
pressure and systolic election period The net physiologic effect of beia-adronerqic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity
In dosages greater than required for beta blockade, INDERAL also exerts a quinidme-like
or anesthetic-like membrane action which affects too cardiac, acaoi. potential The. signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the piat vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because Of pathologic or
functional changes, sympathetic activity is detrimental to. the patient But there are also
situations in which sympathetic stimulation Is vital. For example! in patients wTOTseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results In bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; It may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic, INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol Is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL.
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory tunction in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, If necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action ot digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy Is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
j agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to tollow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Loomallergic Bronchospasm fe.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS, INDERAL should be administered with caution since it may block bronchodiia-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking th g
prior to ma|or surgery is controversial. It should be noted, however, that the impaired ab^j
the heart to respond to reflex adrenergic stimuli may augment the risks ot general anest '5i|
and surgical procedures,
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of ;a
receptor agonists and its effects can be reversed by administration of such agents,. j
dobutamine or isoproterenol However, such patients may be subiect to protracted sn
hypotension. Difficulty in starting and maintaining the heartbeat has also been reportedil
beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent th p
pearance of certain premonitory signs and symptoms (pulse rate and pressure changMj
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be ;>ij
difficult to adjust the dosage of insulin.
THYROTOXICOSIS Beta blockade may mask certain clinical signs of hyperthyroi)^
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of syrnfM
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function q
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases haveii
reported in which, after propranolol, the tachycardia was replaced by a severe bradycjj
requiring a demand pacemaker. In one case this resulted after an initial dose of ;i|
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with imp,*
hepatic or renal function, INDERAL is not indicated for the treatment of hypertejvi
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pajil
should be told that INDERAL may interfere with the glaucoma screening test, Withdrawa a
lead to a return of increased intraocular pressure
Clinical Laboratory Tests : Elevated blood urea levels in patients with severe heart dis *
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as 1
pine should be closely observed if INDERAL is administered. The added catecholai e
blocking action may produce an excessive reduction of resting sympathetic nervous a< it
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or ortho
hypotension.
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals «
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stud
both rats and mice, employing doses up to 150mg/kg/day. there was no evidence of sigm
drug-induced toxicity There were no drug-related tumorigemc effects at any of the dc
levels. Reproductive studies in animals did not show any impairment of fertility tha
’ attributable to the drug
Pregnancy Pregnancy Category C. INDERAL has been shown to be embryoto
animal studies atdoses about 10 times greater than the maximum recommended human
There are no adequate and well-controlled studies in pregnant women INDERAL si
be used during pregnancy only it the potential benefit justifies the potential risk to the
Nursing rs INDERAL is excreted in human milk. Caution should be exercised
NDI I iAI s, adminis'e-ed ,'.o a nursing woman
Pediatric Use j Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most Adverse effects have been mild and transient andjn
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive heart taiture, intensification of AV block; i d
tension; paresthesia of hands; thrombocytopenic purpura, arterial insufficiency, usually j ii
Raynaud type
Central Nervous System: iigtiitieadedness. mental depression manifested by insoja
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia, ya
disturbances; hallucinations; an acute reversible syndrome characterized by disorientatl io
time and place, short-term memory loss, emotional lability, slightly clouded sensoriumTl
decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diar a
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with a‘.i<
and sore throat, laryngospasm and respiratory distress,
Respiratory: bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytoiiil
purpura
Auto-Immune: In extremely rare Instances, systemic lupus erythematosus has IS
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male i o
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous rearjnl
involving the skin, serous membranes and conjunctivae reported for a beta blocker (prac )l
have not been associated with propranolol,
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochlorid i
sustained-release capsule for administration once daily. If patients are switched from INDll'l
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapx
effect is maintained INDERAL LA should not be considered a simple mg for mg substitda
INDERAL, INDERAL LA has different kinetics and produces lower blood levels. Retitratiorps
be necessary especially to maintain effectiveness at the end ot the 24-hour dosing mt al
HYPERTENSION — Dosage must be individualized The usual initial dosage is 8SI(
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage m;;)i
increased to 120 mg once daily or higher until adequate blood-pressure control is achi-o
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage cj|
mg may be required The time needed tor full hypertensive response to a given dose) is
variable and may range from a tew days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDER/ L
once daily, dosage should be gradually Increased at three to seven day intervals until opt In
response is obtained. Although individual patients may respond at any dosage leveffl
average optimum dosage appears to be 160 mg once daily In angina pectoris, the valuHO
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few vjkS
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDER/J
once dally. The usual effective dose range Is 160-240 mg once daily The dosage m.:)e
increased gradually to achieve optimum migraine prophylaxis If a satisfactory response id
obtained within four to six weeks after reaching the maximum dose, INDERAL LA thjjj
should be discontinued It may be advisable to withdraw the drug gradually over a per ! <J
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once dally.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group
limited to permit adequate directions for use
‘The appearance of INDERAL LA capsules Is a registered trademark of Ayerst LaborafS
883214
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
642
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
tERIATRIC IMPERATIVE: THE INTERFACE BETWEEN
he Acute Hospital and Long-Term Care
William J. Kane, m.d., and David C. Kennie, m.g., ch.b., mount holly*
The potential for increasing health care costs to a growing
elderly population is staggering . We propose the creation of an
icute geriatric unit and an examination of the hospital role in
ong-term care.
In the last few years, medical
education has begun to address
the needs of physicians for
scific skills and knowledge in the care of the aged
tient. Yet, in the absence of an appropriate care de-
siy system, the individual physician, no matter how
illed, is limited in his/her ability to deliver quality
re to the elderly. The appropriateness of the health
re delivery system is more important for this age
tup than for any other subpopulation; therefore a
reful examination of the role of the acute hospital
necessary.
\ health care system for the elderly must develop
thin constraints imposed by a modem competitive
defy. The development of a comprehensive system
U be stimulated by two factors, cost and the impedi-
nt to the efficient function of the acute hospital,
total costs of Medicaid, the biggest provider of long-
m care, have risen from 1.3 billion dollars in 1965
18.6 billion dollars in 1978. Forty-one percent of this
lount went to nursing home care.1 With the number
elderly in the population doubling in the next 50
irs, the potential for increasing health care costs is
ggering. As the cost and complexity of acute hospi-
care continues to increase and prospective reim-
rsement gains momentum, elderly patients awaiting
nsfer to long-term care facilities become a major
)blem. In selected areas of the United States, es-
j'ially in our urban areas, the problem is just begin-
L. 81— NUMBER 8— AUGUST 1984
ning. In New York, it was found that Medicare and
Medicaid recipients made up 55.6 percent of the occu-
pants of acute care beds and that almost 1 1 percent
of these were awaiting transfer to nonacute facilities.2
In Massachusetts, in 1983, it was found that 823 elder-
ly patients were awaiting transfer on any given day and
that this amounted to almost 300,000 patient days
annually in that state alone.3
If we are to have a comprehensive but reasonable
health care system for the elderly which addresses
both cost and blocked beds, more attention must be
paid to hospital care of the aged. Much effort has been
expended to identify high-risk elderly in order to keep
them at home and to prevent institutionalization. It
often is difficult to identify and intervene with those
elderly at risk because the major precipitating factor
nearly always is illness with the secondary effects of
illness or trauma on function. Often, the common de-
nominator is an admission to an acute-care hospital
which unfortunately often is prepared poorly to care
for the frail, impaired, elderly patient. The patient's
level of functional ability is allowed to deteriorate in
the hospital so that the patient no longer can cope with
the premorbid level of community support.
*Dr. Kane is Vice-President, Medical Affairs. Memorial Hospi-
tal of Burlington County, Mount Holly, and Dr. Kennie, is
Consultant Geriatrician, Stirling Royal Infirmary, Stirling,
Scotland.
643
The considerable extent of functional impairment
among the elderly in hospitals previously has been
shown.4 A recent survey, on which the authors col-
laborated, examined patients 70 years and over in a
400-bed community hospital affiliated with a univer-
sity medical center. The study found that more than
half of the patients 75 years or older needed assistance
with activities of daily living; 34 percent had impaired
hearing, 40 percent had impaired vision, and 25 per-
cent had speech impairment. Fifty-four percent of pa-
tients aged 85 and older were moderately or severely
disoriented. Incontinence of urine or stool was present
in 21 percent of the patients. Physical therapy was
ordered on only 30 percent of the patients and social
services were involved in only 40 percent of the ad-
missions, largely for discharge planning.5
The acute hospital does not cope well and was not
designed for the elderly patient. Today, the patient
usually is confined to a single room, which may be a
form of sensory isolation. Any pre-existing confusion
may be aggravated. Existing policy does not make it
convenient for patients to walk about and in order to
achieve conformity with rigid hospital systems, physi-
cal or chemical restraint often is imposed. In the
survey quoted previously, psychotropic medications
and sedatives were being prescribed for 43 percent of
the patients over the age of 70. Impaired mobility and
incontinence often wrere a consequence of this re-
straint.
Because of the special needs of hospitalized elderly
patients, we advocate the creation of a functionally
oriented unit as a discrete area in the hospital where
the needs of the veiy old can be met by a combination
of correct policy and suitable environment. Such
special units already exist in our hospitals for pedi-
atric, obstetric, and psychiatric patients.
This acute unit would have a comprehensive
assessment and triage system to meet the medical,
functional, and support needs of the elderly patient.
Policy would seek the promotion of independence
rather than dependence. Physical therapy would take
place within the unit and on a repetitive basis
throughout the day rather than in one short session
in the physical therapy department. The staff would
form a multidisciplinary team and spend additional
time working with families and the attending phy-
sician in discharge planning. Teamwork with regular
case conferences and close scrutiny of drug prescrib-
ing also would be a part of this unit. Nursing staff
would be selected and rewarded for expertise in
geriatric care, achieving clinical distinction as in criti-
cal care and maternal and child health.
An evaluation of this concept absolutely is necessary
to prove its superiority to a regular medical/surgical
unit. Parameters such as level of function at discharge
for any diagnostic group, the rate of discharge to nurs-
ing homes, the use of physical and chemical restraints,
cost, patient and family satisfaction, and staff at-
titudes and approach to the elderly could be measured.
While many aged patients can be discharged suc-
cessfully to the home within several days from a func-
tionally oriented hospital unit, some will not and they
ill require longer periods to regain their full potential.
samples of such patients would be stroke patients
th barriers to rehabilitation and patients with am-
putation or hip fractures with cardiorespiratory pn
lems or resolving confusional states. Such patie <
may have no long-term need for a nursing home, 't
must examine our long-term care facilities and tl ;
success in rehabilitation and return of the elderh<
the community.
The usual nursing home does not focus sufficiei v
on the elderly with rehabilitation potential. Most fa< i
ties mix patient groups. Elderly patients with seif
dementia who are confused and restless are mi |
with patients who are seriously ill requiring parent) |
nutrition, turning, and vital signs. Frequently sal
wiched between these two is the elderly patient v
a mild stroke and good prognosis. Despite this pi ;
nosis, recoveiy and discharge may be impeded beca ?
simple rehabilitative measures will be difficult du( )
the excessive strain on staff time imposed by the ot r
two patient groups. The conventionally protect j
nature of nursing care required for these veiy dep
dent patients also detracts from the rehabilitat 1
where the patient is encouraged to be an active part
pant and take care of him- or herself.
There must be much more careful multidisciplin ,
assessment of patients entering the nursing hoi.
Specific attention must be paid to the rehabilitat ;
potential and to consideration of placement in a c
tinct area of the facility. These patients would be gi\ii
a definite period of time in such an area to achi;:
discharge or independence and after that time be
A system must be designed
to control the cost of health
care for the elderly while
improving the quality of
care.
itmmmm'mmrn-'t iiifKiiwiiri— w—
located in the facility. This rehabilitation unit with
the nursing home would be protected bed space a
would never operate at full occupancy. In this w
patients could be transferred readily from the hospi
and continual turnover would occur.
To develop the acute hospital unit and the rehab
tation unit within the nursing home, reimburseme!
incentives will have to change. In the hospital, thii
party payors may have to pay slightly more for hospit
ization to reduce the need for long-term care. In tl
nursing home, adequate reimbursement will have
be available to provide rehabilitation to those patier,
with excellent potential. In addition, nursing hom
will have to receive some incentive to encourage retu
to the community rather than the current situatii:
which financially encourages nursing homes to ke
their beds full with the least disabled patient for t
longest period of time.
In addition to changes, within the acute hospital aij
the long-term care facility, a supportive commun
environment will have to be maintained. Better respi
for families, adequate home care, and other servic;
are essential. Such services should be allocated or
after multidisciplinary assessment, including a kno\,
edgeable physician, determines true need. The curre
situation allows need to equal demand and, often, tn.
644
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
>edy patients do not receive a service because it is
dng given to less needy patients who have better
cessibility or competent advocates such as family or
icial services.
JMMARY
A system must be designed to control the cost of
>alth care for the elderly, while improving the quality
care. Hospitals now are faced with a Medicare pro-
lective reimbursement system which requires a new
id comprehensive look at services delivered to elderly
itients. This paper suggests two changes. The first
a change in hospital services to accommodate the
derly who because of illness or trauma are admitted
a hospital and who must have their function main-
ined to achieve discharge back to the community,
iicondly, hospitals must foster changes in long-term
Lre to increase rehabilitation and provide quicker and
ore frequent return to the community of the elderly
ith the potential to do so. Multidisciplinaiy assess-
ent in the hospital, in the community, and in the
ng-term care facility will be necessary to accomplish
these goals. By carefully examining the interface be-
tween the acute hospital and long-term care in the
community and in the nursing home, hospitals suc-
cessfully can deal with prospective reimbursement,
prevent blocked beds, and, in the long run, provide
better care for the elderly in their community.
REFERENCES
1. Health Care Financing Administration Medicaid
Statistics, 1978. DHEW Publication Number (HCFA)
78-03154.
2. New York Statewide Professional Standards Review
Council, Inc.: Report on a statewide survey of patients await-
ing placement for alternate care facilities in New York state.
New York, NY, June 1979.
3. Campion EW. Bang A May MI: Why acute care hospitals
must undertake long-term care. N Engl J Med 308: 71-75,
1983.
4. Donahue W, et al.: Rehabilitation of geriatric patients in
county hospitals. Geriatrics 263-274, 1960.
5. Warshaw G, et al.: Functional disability in the hospital-
ized elderly. JAMA 248:847-850, 1982.
6. Winston R et al.: External peer review of skilled nursing
care in Minnesota. Am J Pub Health 66:278-283, 1976.
t
1
I
!
L. 81— NUMBER 8— AUGUST 1984
645
600 mg Tablets
£>1984 The Upjohn Company
The Upjohn Company • Kalamazoo, Michigan 49001 USA
j-4044 JanJ
rERIATRIC IMPERATIVE:
kN Opportunity For Change
Ionald B. Milch, passaic*
\ re-examination of the roles of hospitals and physicians is needed
for success in meeting the health care demands of a growing
elderly population, with as much emphasis required on extended
ind essentially palliative care as on acute, curing care . General
~e commendations and specific changes are described.
The growing number and percent
of older Americans has
produced a steady rise in the de-
nd for health care services and pressure for change
the way they are provided.
ome Somers and others refer to the health care field
acing a “geriatric imperative” and warn that effec-
‘ responses are overdue.
his article describes how the geriatric imperative
5 addressed by the Committee on Aging and Long-
m Care of the New Jersey Hospital Association
HA)— a committee the author chaired — and then
s on to summarize some of the activities under-
en at Beth Israel Hospital, Passaic, and the direc-
i in which we expect to travel in the future,
iter more than a year of research and reflection, the
nmittee established by NJHA to consider the role
lospitals in serving the elderly decided that it was
important to prescribe norms as it was programs,
fact, it was the Committee's view that the overall
itent was more important than specific activities,
he Committee selected four elements for focus by
lj New Jersey hospital industiy and an additional
t r for individual hospitals and their chief executive
►Jeers (CEOs): In terms of the New Jersey hospital
ijustry, the Committee urged:
1- The industry must encourage professional eduea-
iji in geriatric care in both professional and continu-
education and foster research in geriatric care.
2. The industiy must support changes in state and
federal laws and regulations that reduce the institu-
tional bias of current reimbursement programs, sup-
port alternative services, require financial impact stud-
ies of existing and proposed licensure regulations, and
centralize state funding of care for aged and chronical-
ly ill. The Committee also urged tax credits for family
support systems and a state system for developing
diagnostic data for patients on the Medicaid nursing
home waiting list.
3. NJHA should establish a standing committee on
aged and chronically ill, establish positions on ease
mix reimbursement system for long-term care facili-
ties, and on other policy matters, including insurance
for long-term care, copayment for Medicare, and family
supplements for Medicaid benefits.
4. Hospital-sponsored research should be en-
couraged through the Health Research and Educa-
tional Trust (HRET) of New Jersey, with certain spe-
cific activities accorded high priority: a study of the
sensitivity of the DRG system to age of patients, de-
velopment of a statewide directory of hospital pro-
grams for older adults and a manual of program
prototypes and other resources, and, finally, a broad
study of the impact of a growing geriatric population
on hospital operations.
In terms of individual hospitals and their CEOs, the
*Mr. Milch is Executive Director. Beth Israel I lospital. Passaic.
L 81— NUMBER 8— AUGUST 1984
647
Committee urged each to do the following:
1. Establish geriatric care as a high priority by
recognizing the geriatric population as a growth por-
tion of health care business, by conducting ap-
propriate local marketing studies and by working to
differentiate between patient needs and patient wants.
2. Establish geriatric care standards. Each hospital
should establish geriatric care committees, including
professional staff of all disciplines, to recommend hos-
pital policies and procedures and develop approaches
to change in existing services, such as geriatrics medi-
cal/surgical units or other selected geriatric care pro-
grams.
3. Promote standards of geriatric care. The Commit-
tee felt this could be accomplished best by conducting
a hospital-wide analysis, including surveys of staff at-
titudes and aptitudes, and by providing inservice
training.
4. Assume community leadership role by conduct-
ing assessments of community services and partici-
pating in case management systems. The Committee
felt it was time for hospitals to establish broader links
to community-based agencies and to help facilitate
interaction between hospitals, physicians, and com-
munity agencies.
At Beth Israel Hospital, the geriatric imperative has
been an important part of planning since the middle
1970s and we believe we have successfully converted
the challenge presented by the elderly into a plus for
the hospital, at least for the mid-term.
However, a re-examination of the role for which most
hospitals believe they were created is required for long-
term success.
BETH ISRAEL HOSPITAL
The 223-bed Beth Israel Hospital, Passaic, shares a
service area of less than 180,000 persons with two
larger hospitals, each less than two miles distant. Ad-
ditional competition is offered at the edges of the area
by other hospitals. The 1980 Census found population
in the area declined 7.6 percent and state planners
forecast somewhat smaller losses in the decade ahead.
Passaic— the core city in the service area— showed de-
creases in both number and percent of the elderly
although the picture was balanced somewhat by gains
in the neighboring city of Clifton.
In the face of the stiff competition and lack of popu-
lation growth — including that of the elderly popu-
lation— Beth Israel Hospital has improved its utiliza-
tion, developed new and expanded services, added to
its medical staff, improved its operating margins, and
undertaken a major modernization program that place
the hospital in a sound competitive position for the
1980s.
The hospital’s accomplishments were not accidental.
They were based on a continuous long-range planning
process conducted at the Board of Trustee, CEO, and
medical staff leadership levels that helped frame policy
questions and clearly articulate policy decisions.
We began by affirming that Beth Israel Hospital was
more than an acute care institution. We consider our
hospital a community "helping” resource, rather than
an institution organized solely to provide acute medi-
cal care. We want to serve through a variety of health
and health-related activities. Railroads viewed L
selves too narrowly. They considered themselves 3
systems, rather than transportation systems; it (
them dearly. We feel hospitals ought not to repeat h
kind of mistake.
We accepted the “geriatric imperative” as real)
mirrored in our overall service area, if not in theoi
area in which the hospital itself is located. We acki w
edged that elderly patients were key customers 1;
likely to remain so. They were not a special mi^
group. They were the solid base of our patient ar
Confronting the geriatric
imperative means that the
changes underway are moni
in the nature of obligatory
acts.
Over a period of five years we have expanded 1
developed the following to help serve them:
• A Beth Israel-based, tri-hospital home care n
gram.
• A hospice home care extension.
• A Personal Health Service homemaker projla
intended for self-pay patients and for eventual nj
agement as a separate, for-profit corporation.
• A Community Health Service, emphasizing n
munity health education and outreach service.
• Agreement with the medical staff to establish!
campus primary care centers, including at leashr
emphasizing gerontological care.
• Corporate restructuring to permit new ventur i
housing for the elderly, sheltered care, day care, n
life care.
• Awareness of the needs of the elderly in the a
rier-free design of the major renovation and di
emization program at the hospital.
• Changes in professional and other staff trai r
to emphasize the needs of the elderly.
Other specific elements were added as well, if
include senior feeding (kosher meals, special diets 11
other foods for the elderly in several surrour. n
towns), podiatric care, and a community lifeline ri
gram, coordinated through the hospital’s emerpif
room.
Have the activities been of benefit to the hosp al
The indicators are positive. From 1977 — shortly t(
the commitment to confront the geriatric n
perative — through 1981, the hospital’s occupancy
went from 70.9 percent to 80.8 percent, as admissn
rose from 7,400 to 7,900 in an area that was exper if
ing an overall loss of population. Neighboring hosp al
grew at less than half the rate of Beth Israel Hosj a
The elderly played a significant role in the Beth I ai
Hospital improvement: Medicare days rose fron 4
percent of all days in 1977 to 50 percent of all ay
in 1981 and an indicated 52 percent in 1982.
Home care visits rose from 25,000 in 1977 to 5C 0
in 1982, not including visits by the Personal H< t
Service established for self-pay patients. Last a
home care generated outpatient revenues of more a
two million dollars.
648
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JEF IS
The effort goes on. Planning, implementation, evalu-
: on, and replanning proceed in a continuous loop.
I it everything goes well. Not all projections are met.
Looking into the future we see hospitals, particularly
lose in the older, more stable suburbs, remaining
c acial to any improved system of care for the elderly.
1 me believe hospitals to be largely irrelevant to the
cronic care needs of the elderly. We disagree. Hospi
I s are highly visible and available 24 hours a day,
s/en days per week, every week of the year. They are
td will remain prime points of access, as will doctors’
tiiices. In time, the hospital role may shift and lead to
E greater emphasis on gatekeeping: assessing the over-
e needs of geriatric patients and coordinating the
\rious medical, social, and other services required as
jic patient steps through the gate into a more rational,
lig-term care system.
iDertainly, hospitals will be more involved in primary
E d preventive care for the elderly, either directly or in
operation with those members of its medical staff
uo orient their practice to the elderly. We also will
tgin to mass services required to stabilize the acute
fisodes of those with chronic illness while becoming
ore deeply involved in rehabilitation and transition
home.
furthermore, in exercising our responsibility to the
lerly, all of us in health care must come to appreciate
at many needs are psychological and social in nature
well as physical — and that these elements are in-
aarable from the care we provide. As a result, services
the elderly will be provided by many disciplines and
pfessions, functioning through multiple agencies. A
= ccessful health system for the elderly will require the
i
critical mass of management skills of a hospital to
effectively coordinate all those resources, whatever
their configuration.
Hospitals can provide service directly and they will.
They can provide space within the hospital complex for
others to offer services and many will. Indeed, the new
administrative technique of organizing the hospital
into a holding company, with individual corporate en-
tities formed around disparate but related functions,
has promise for enabling hospitals to greatly broaden
their ability to plan and participate, whatever the ser-
vice, whoever renders it, or wherever it is located.
SUMMARY
Hospital personnel and physicians are trained to
provide acute, curing care. However, the inevitable con-
sequences of aging have forced our single biggest
users— the elderly — to become purchasers of care that
is extended and essentially palliative, and, as they say
in the marketing terms currently fashionable in hospi-
tal circles: “What you are selling is less important than
what people are buying.”
It is a considerable change for hospitals and for doc-
tors but it is one demanded by the needs of the people
we serve — it is demanded by the geriatric imperative.
In short, confronting the geriatric imperative means
that the changes underway in how we treat the elderly
are more in the nature of obligatory acts — ones we
cannot and should not avoid or evade.
Hospitals and doctors that adapt best to these obli-
gations are those most likely to succeed and prosper
in the years ahead.
1
i
L. 81— NUMBER 8— AUGUST 1984
649
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For Full Prescribing Information, Please See PDR.
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iERIATRIC IMPERATIVE:
Geriatric Assessment Programs
Laurence Z. Rubenstein, m.d., m.p.h., sepulveda, ca*
This article reviews geriatric assessment programs and their
history , purpose , structure , and the growing indications that they
are effective in producing improved health care outcomes such
as better diagnoses, reduced nursing home placement, decreased
medications, and higher junctional status levels.
Growing awareness of the vast
numbers of unmet health and
psychosocial problems faced by
lerly individuals, has led medical care providers to
tablish special programs to comprehensively assess
td treat elderly patients. This presentation will
ovide a geriatrician’s perspective on geriatric
sessment programs by describing: (1) the purposes
assessment: (2) the different structural and func-
mal components of assessment programs; (3) exam-
es of existing programs; and (4) some of the evidence
at these programs are achieving their goals.
Geriatric assessment has several major purposes,
lese include diagnosis and establishing baseline
ita for documenting change, planning for therapy
td for most appropriate services, and determining
dimal placement. Diagnosis means medical
agnosis as well as the functional, psychologic, and
cial diagnosis. This especially is important in light
the accumulating evidence that elderly individuals
ten are diagnosed incompletely and inaccurately
hen cared for in the usual medical setting without
special geriatric approach. Careful, systematic
sessment can lead to the discovery of important,
eviously unrecognized, treatable problems.
Avoidance of inappropriate use of health care ser-
ies, especially those in institutions, has been a major
jective of most geriatric assessment programs on
ounds of both compassion and cost. Several studies
)L. 81— NUMBER 8— AUGUST 1984
summarized in the United States Government Ac-
counting Office Report of 1979 concluded that at least
20 percent of patients in skilled nursing facilities and
over one-third of patients in intermediate care facili-
ties receive unnecessarily high levels of care.1 Such
inappropriate use is undesirable for several reasons,
including wastefulness of scarce resources, creation of
further disability by premature labeling of a person as
irremediably ill, and iatrogenic illness which is com-
mon within institutional environments. There is
substantial and growing evidence that assessment can
lead to improved appropriateness of placement.
HISTORY OF GERIATRIC ASSESSMENT
The first published reports on geriatric assessment
programs came from Great Britain. Dr. Marjorie War-
ren, a physician considered one of the founders of
modem geriatrics, initiated the concept of specialized
geriatric assessment units during the late 1930s while
in charge of a large London infirmaiy. This infirmary
was filled primarily with chronically ill, bed-fast, and
largely neglected elderly patients who had not received
proper medical diagnosis or rehabilitation. The high
quality of the nursing kept the patients alive while the
lack of diagnostic assessment and rehabilitation kept
them disabled. Warren systematically evaluated these
*Dr. Rubenstein is Chief, Geriatric Evaluation Unit. VA Medi-
cal Center, Sepulveda, California.
651
TABLE 1
Geriatric Assessment Programs:
Characteristics and Variants
Intended function
Assessment
Rehabilitation
Acute or chronic treatment
Placement
Education
Research
Location/setting
Acute hospital
Chronic hospital
Long-term care facility
Outpatient clinic or office
Freestanding unit
Patient homes
Patient source
Community (direct application or referral)
Acute hospital
Long-term care facility
Inclusion criteria for patients
Minimum age (e.g. > 65. > 75)
Type of problem (e.g. psychiatric, placement)
Degree of disability (e.g. inability' to function
independently)
Exclusion criteria for patients
Poor prognosis
Unstable condition
Organization
Team composition
Participating support service
Size of unit
Patient-to-staff ratio
Payment source
Followup capacity
Time allowed for assessment
Approach to assessment
Dimensions included
Testing of actual performance v presumed capability
Use of test batteries v clinical judgments
Types of recordkeeping formats
patients and began policies of mobilization and selec
tive rehabilitation. She was able to get most of the long
bed-fast patients out of bed, often walking again and,
in some cases, even discharged to home. As a result
of her experiences. Warren became an advocate of com-
prehensive assessment and at least an attempt at re-
habilitation of all elderly patients before sending them
to long-term care hospitals.2
In the United States, geriatric assessment programs
have emerged only in the past decade, however, their
proliferation has been rapid in the last three or four
years. These programs have a wide variety of structural
and functional components, geared to differing types
of populations and problems addressed, but they also
share many common characteristics. Virtually all pro-
grams include the use of multidimensional assess-
ment. utilizing one or more sets of measurement in-
struments to quantify functional, psychologic, and
social parameters. Most of them use interdisciplinary
teams to pool expertise and enthusiasm in worl)t
toward common goals. Most attempt to couple U
assessments with an intervention program, suclaj
rehabilitation, counseling, or placement.
PROGRAM CHARACTERISTICS
Some of the major characteristics which can -
between programs are listed in Table 1. A variet
overall functions can be performed by these progn
While assessment is common to all, many also inc
treatment and rehabilitation; some include acute
and most include the determination of optimal pi
ment. Research and education are important asp
of some programs, and generally have profound
pacts on programmatic structure.
Program location largely determines the types ol
tients assessed and functions perfonned. Assessn
programs in acute hospitals generally admit path
from acute inpatient services, though many also ac
directly from the community if inpatient care is
quired. Hospital programs usually combine treatn
and rehabilitation with assessment and placemli
Outpatient clinics or freestanding units gene
assess patients not requiring hospitalization i
usually do not perform substantial treatment os
habilitation. Programs performing assessment in
tient homes can obtain unique insights into how
tients live and function at home, but the costs i
logistical problems associated with home visits 1
the size and scope of home assessment prograrr
Referral sources for patients, as well as the
elusionary and exclusionary admission criteria i
by programs, also depend on the program setting
intended functions. Although age criteria admitt
are arbitrary, programs usually insist that patient)
at least 65 years old; some have a higher minimum
to insure that the programs retain their “geriau
missions, and do not become programs earing for i
viduals with chronic disorders of all ages. Some t
grams have geropsychiatric orientation and prim;;
accept patients with problems such as dementia i
depression. Others, situated on acute medical serv
accept patients with acute medical problems. 1VI
however, primarily accept patients with subacute i
chronic problems not requiring acute medical
surgical hospitalization yet who are at great risf
requiring long-term institutional care.
Programs providing substantial inpatient treatn!
or rehabilitation can increase their impacts by inc
ing only patients with reasonable “rehabilital
potential." However, prognostication is at best an i
act art and every geriatrician knows many instar
when patients not expected to do well have made
markable recoveries. Some risks of failure mus i
taken, since accepting only patients expected tc i
cover or rejecting patients on the basis of a poor p i
nosis easily can become self-fulfilling.
Organization of assessment programs varies <j
siderably, but most include a core team of a physin
or physician assistant or nurse practitioner, a rn
and a social worker. To this core is added a varied
other specialists, who either participate in the b if
assessment or are called in on a consultation basis §
psychologist, psychiatrist, occupational thera]T
physical therapist, audiologist, dentist, optometrist
652
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JEF f
hthalmologist, dietitian, public health nurse, and
lers). The size of the team is influenced by several
’tors, including program goals, setting, patient load,
d funding or reimbursement levels. Most funding
urces and insurance companies have restrictive
stations as to what services will be paid for and this
pfoundly affects what services can be offered. How-
>r as evidence accumulates that these programs can
cost effective, not only in improving quality of life
|t in reducing overall health care costs for the elderly,
iding sources probably will expand.
Approaches to assessment vary between programs,
pending upon programmatic goals and settings.
>st include a multidimensional assessment in which
j>st or all of the areas of medical problems, functional
’-.abilities, psychologic status, and social network and
eds are covered.
fable 2 lists the most important measurable
nensions of geriatric assessment. Some programs
I? a comprehensive test battery or multidimensional
bessment to achieve this, while others select from
long the existing unidimensional instruments best
;ted to their particular programs.
While geriatric assessment perse does not absolutely
juire the use of specific instruments and scales, the
; of easy-to-administer, well-validated assessment
■truments encompassing the major domains of
iatric assessment makes the process of assessment
rsiderablv easier to perform and teach, and certainly
ire reliable. In addition, these instruments facilitate
nsmission of understandable clinical information
,ween health providers, permitting smooth team-
!rk to occur, meaningful and valid data to be
jtulated, and therapeutic progress to be measured
?r time.
'he recent book on assessing the elderly by Robert
i Rosalie Kane provides an excellent analysis on the
sting geriatric assessment instruments, and de-
ibes in detail which are best for each particular
ting and patient population.3 In our experience, the
'St important assessment instruments, providing
la not ordinarily obtained on the standard medical
dory and physical examination, are those instru-
Ints in the areas of psychologic functioning (a
(nitive function screen and a screen for depression)
i overall functional status (a scale for measuring
ivitites of daily living— ADL).
RIATRIC ASSESSMENT UNITS
lost geriatricians firmly are convinced that
jiatric assessment programs are effective in improv-
both the process and outcome of geriatric care,
m though well-designed studies clearly leading to
;s conclusion only now are beginning to appear. The
ny published reports on geriatric assessment units
,.Us) all show clear associations between the pro-
ms and major improvements in care outcomes,
ugh these reports have been based only on descrip-
j or quasiexperimental studies. Among these re-
ded improvements from GAUs, summarized in
|»le 3, are improved diagnostic accuracy, placement
iition, functional status, and use of medications.4
he first report to describe the success of a program
he United States was published in 1973 on data
n T. Franklin Williams’s outpatient assessment
I,
TABLE 2
Measurable Dimensions in Geriatric Assessment
Physical health
Diagnoses/conditions present
Physiologic severity indicators
Quantification of medical services used
Self-ratings of health or disability
Functional ability
Activities of daily living (ADL) scales
Instrumental ADL scales
Psychological health
Cognitive function (mental status)
Affective function
Social parameters
Social interaction network
Social support needs and resources
TABLE 3
Improved Patient Outcomes
Which Can Derive from Geriatric Assessment Programs
• Improved diagnostic accuracy
• More appropriate placement
• Less dependency on skilled nursing facilities
• Improved functional status
• More appropriate use of medications
• Better coordinated use of available community support
sendees
• Improved emotional status and sense of well being
program in Monroe County, New York.5 Williams's pio-
neering program assessed all patients referred for
nursing home placement in the county in an attempt
to insure the appropriateness of these placements and
to decrease unnecessary use of long-term care facili-
ties. They found that only 38 percent of patients re-
ferred for nursing home placement actually needed
such skilled nursing care, while 23 percent of the pa-
tients were able to return to their homes and 39 per-
cent were able to go to board and care facilities or
retirement homes following careful assessment and
recommendations for specific therapy. Expert judg-
ments made by an independent team of observers as
to the appropriateness of placement locations before
and after the initiation of the Monroe County program
indicated that major improvements in placement de-
cisions were being made— from 50 to 60 percent ap-
propriate before to 84 percent appropriate afterward.5
Several others have reported similar improvements in
placement locations associated with assessments on
GAUs, including our group at the Sepulveda VA, who
showed improvement in placement location by over 50
percent of patients going through the GAU, based on
judgments by the referring physician.6
Several reports have examined patients’ functional
status before and after treatment on those GAUs which
include rehabilitation along with the assessment.
These reports usually have used a validated measure
of functional status, such as the Katz Index of Ac-
tivities of Daily Living (ADL) to document change-over
time.7 They uniformly show that many patients im-
prove during their stays on the GAUs. (Our paper from
the Sepulveda VA reported improved functional status
, 81— NUMBER 8— AUGUST 1984
653
in over two-thirds of patients.6) However, the lack of
control groups in most of the reports prevent a skep-
tical reader from concluding that the improvement
came clearly from the GAU, rather than from the effect
of time.
Another major area of GAU impact is the improve-
ment in diagnostic accuracy, usually indicated by the
diagnosis of new, treatable problems. Many have found
large numbers of previously undiagnosed problems re-
sulting from careful GAU assessment. Depending on
each study’s criteria for considering newly docu-
mented problems as new diagnoses (some only
counted major new treatable problems), new diagnoses
were found in frequencies varying from 0.76 per pa-
tient to almost 4 per patient. Most of these new
diagnoses seemed to stem from an awareness that
elderly patients need a more thorough search for
treatable problems, although they also might reflect a
lack of diagnostic thoroughness in the referring ser-
vices.
Improvement in quality of treatment is difficult to
quantify. One measurable parameter, use of prescrip-
tion drugs, was examined in several programs. In those
programs, drug prescribing generally was made more
appropriate and usually was decreased in quantity,
despite a concurrent increase in the number of
diagnoses identified. (Our GAU paper reported over a
one-third reduction of prescribed drugs).6
Two recent controlled studies have begun to confirm
these descriptive reports. They also show that control
group patients who survive the initial hospitalization
also tend to improve in functional status over time,
though not as much as those on the experimental unit.
This indicates that not all the functional status im-
provement described earlier can be attributed to the
GAU itself. Nonetheless the benefits from GAUs, at least
to certain subgroups of elderly patients, are becoming
more and more evident.
Lefton and Frengley published data from a retro-
spective case control study on their inpatient GAU at
a rehabilitation hospital.8 In their study, 50 con-
secutive patients aged 70 and over discharged from
their GAU were compared retrospectively with 50 con-
trol patients discharged from other medical wards in
the same facility, matched for age, sex, and primaiy
diagnosis. Mean length of stay for patients in the two
groups were comparable and fairly long (68.0 and 70.7
days, respectively), but reflected the extensive rehabili-
tation being performed along with the assessment.
Discharge location significantly was better for the GAU
group than for the control group (80 percent versus
62 percent were discharged to home settings, and 20
percent versus 38 percent to nursing homes, respec-
tively). Patients in the GAU were more likely than con-
trol patients to improve their functional status (Katz
ADLs, independent ambulation, and continence
status) during their hospitalizations. At followup
evaluations, performed several months after discharge,
the living locations had not changed substantially, and
significantly more GAU than control patients were still
at home. However, functional status of control patients
had improved at followup so as to approach the levels
of the GAU patients.8
Our group at the Sepulveda VA Geriatric Assessment
Unit has been conducting a prospective randomized
experiment, comparing outcomes of frail elderly inp
tients randomly assigned to enter the GAU or to eoi
tinue receiving care on their acute hospital wards. Th
study still is in progress, but preliminary data indica
significant reductions in both one-year mortality ar
overall use of institutional services by GAU patients i
compared to control patients. In fact, the savings it
direct medical care costs for the GAU group appear is
be substantial and more than enough to pay for tl
program.
One important goal should be to identify which suli
group of patients can -be expected to benefit particvt
larly from the programs in order to make maximal us 1
of scarce resources. While it might be argued that th I
majority of elderly probably could benefit from carefi ;
assessment, the bulk of older people generally at
healthy, and the relative yield of assessment tends 1 j
be lower for healthy than for frail or ill elderly. In gei ;
eral, those individuals most likely to benefit froi
assessment are those who are on the verge of needinij
institutionalization, who are in the lower socioecdj
nomic groups, who have inadequate primaiy medic;i
care, and who have poor social support network
These at-risk elderly seem to derive especially gretjj
benefits from assessment and associated therapeuti t
interventions.
SUMMARY
There is growing evidence that geriatric assessmen
programs can be effective in improving health car
outcomes for subgroups of frail elderly patients. Th
improvements include better diagnoses, lower rates c
nursing home placement, decreased medications, am
improved functional status. Moreover, recently emer^
ing controlled studies are showing improvements ii
survival and lower medical care costs in particulaj
settings. Such programs need not follow a rigid mode
but rather can be adapted to many different kinds c
settings, both inpatient and outpatient, public secto
and private. If some care is taken to target these ser
vices to those particularly in need, then their prolifers
tion is likely to fill a major gap in health care deliver
for the elderly.
REFERENCES
1. United States General Accounting Office Report; Cos
implications for Medicaid and the elderly. United States Gen
eral Accounting Office. Washington, D.C., 1979.
2. Brocklehurst JC: Great Britain, in Brocklehurst JC (ed)|
Geriatric Care in Advanced Societies. Baltimore, MD, Univer
sity Park Press, 1975.
3. Kane RA Kane RL: Assessing the Elderly: A Practica ^
Guide. Lexington, MA, D.C. Heath, 1981.
4. Rubenstein LZ, Rhee L, Kane RL: The role of geriatric
assessment units in caring for the elderly: An analytic review ,
J Gerontol 37:513-521, 1982.
5. Williams TF. Hill JF, Fairbank ME, et al.: Appropriate
placement of the chronically ill and aged: A successful ap
proach by evaluation. JAMA 226:1332-1335, 1973.
6. Rubenstein LZ. Abrass IB, Kane RL: Improved care for
patients on a new geriatric evaluation unit. J Am Geriatr Socj
29:531-536, 1981.
7. Katz S, Downs TD. Cash HR et al.: Progress in the de
velopment of the index of ADL. Gerontologist 10:20-30, 1970
8. Lefton E, Bonnstelle S, Frengley JD: Success with ar
inpatient geriatric unit: A controlled study of outcome anc
followup. J Am Geriatr Soc 31:149-155, 1983.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
654
Geriatric Imperative:
Hie Acutely III Elderly
Lucille A. Joel, ed.d., Newark*
I
New skill levels of nursing manpower are neededfor acute care
of the aged , as well as a philosophy of care which if put into place
would do much to avoid the profound regression which is so
common when the elderly face episodes of illness.
The face of hospital nursing is
changing. The combination of
governmental strategies to
artail costs through reimbursement methodology
nd the visible graying of America create a new clinical
nvironment in acute care. Real pressure exists to in-
titute aggressive treatment programs and speed dis-
harge. The irony of the situation is that aggressive
cute care management in its usual sense often is
lappropriate to the clinical population being en-
Duntered in the 1980s.
Between 40 and 60 percent of acute care admissions
ivolve patients over the age of 65.' Acute illness is a
eiy real part of aging, and provider professionals have
een slow to admit that both the approach to treat-
lent and the measures of success may markedly differ
'om that which is appropriate to the younger patient,
he aged are a clinical population beset by problems
f chronic illness. The aged do die from heart attacks,
ut usually they represent an acute exacerbation of an
nderlying chronic condition. The elderly are victims
f a slow and insidious onset of illness and frequent
‘ngthy periods of disability. Regardless of the skill of
ledical management, cure usually is not possible. The
icture of chronic illness as a central element in acute
are of the aged is confounded by normal changes in
ae elderly which demand a greater investment in their
are. Slowness becomes a way of life due to decreased
hysieal ability and diminishing acuity of the senses.
Research tells us that it takes 15 percent more time
to deliver nursing care to those over 65.'
The secret to successful acute care of the aged is
provider professionals with special preparation and
sensitivities to deal with the aged; a therapeutic regi-
men tailored to the needs of this group; environmental
adjustments which make independence possible; and
maximum suspension of institutional policies and
routines where they interfere with the patient's nor-
mally effective way of doing things. Each of these topics
deserve thorough exploration beyond the scope of this
paper. Instead the author will aim to raise the reader's
consciousness, and to hope to call to action some
zealots who are ready to make a commitment to the
aged.
Health care professionals have not been turned on
to careers with the aged. The emotional high of thera-
peutic responsiveness and return to wellness is absent.
Recovery, if possible, is fraught with slow progress and
temporary cures. Though one can accept this clinical
picture in long-term care, we have chosen to deny what
is becoming reality in hospitals. This denial may be a
protective mechanism to mask our own insecurity.
Professional providers of all types have been ill-
equipped to deal with the acutely ill aged. We have been
slow in realizing that they are different, and not just
*Dr. Joel is Director, Teaching Nursing Home Project, Rutgers
College of Nursing, Newark.
T)L. 81— NUMBER 8— AUGUST 1984
655
older adults. The goal of confinement may be to re-
define a level of wellness with patients and help them
adjust to it, rather than returning to a previous state
of wellness. Such expectations demand a tedious inter-
personal investment. It is premature to say that this
role does not hold career interest for large numbers of
nurses. Academic nursing has been slow in incorporat-
ing content and experiences specific to care of the aged
into the curriculum. We are apt to be afraid of what
we do not understand. Our poverty of understanding
about the aged has blinded us to the challenges of
gerontological nursing. A recent study in New Jersey
documents patterns of investing fewer nursing re-
sources in the care of the hospitalized elderly than was
true for younger patients. The amount of nursing time
allocated to a patient was related inversely to the age
of the patient. The younger the patient, the greater the
amount of time devoted to their care.2
Creativity in the use of
support systems, activities ,
and meals will contribute to
the total therapeutic effect .
Professionals who recognize care of the aged as a
specialty, and possess the requisite knowledge, skills,
and attitudes are the key to clinical success. Nursing
has begun to address this challenge. Academic nursing
has pioneered programs for primary health care
providers to serve the aged and for tertiary providers
or nurse gerontologists whose practice is charac-
terized by a narrower scope, but more depth in select
areas of clinical management. It already has been
noted that our accomplishments have been less en-
viable in entry level nursing programs. Experiences
with the aged should be as much of a clinical require-
ment as experiences with children or the childbearing
family or the nonaged adult. Faculty should be en-
couraged to pursue researehable questions in geron-
tology and to focus their own practice in care of the
aged.
Given the calibre of specialists suited to provide
clinical direction, these individuals must be put in
positions of authority. Caring for the elderly requires
consistency and sophisticated clinical judgment as
close to the bedside as possible. Delays in problem
identification and therapy can create setbacks which
may become difficult to recoup. For many of the elderly,
wellness is dependent on maintaining a very delicate
balance. They have no energies in reserve to cope with
the demands of an acute episode of illness or to accom-
modate, for even a limited time, to the changes that
come with hospitalization. The vulnerability of the
elderly becomes painfully apparent as well-meaning
health care professionals provoke regression and
diminish once-adequate coping behaviors. All too fre-
quently, a domino effect is set in motion. Strain on one
system stresses another which is fragile, and so on.
Limiting mobility may make incidents of incontinence
difficult to avoid, and this may severely impact on self-
esteem, which may promote social isolation. From
there, it is a short step to confusion, disorientatic,
and additional unacceptable behavior. The re
tionships are obvious. It is not unusual for the ag!
to enter acute care institutions functionally able
cope with community living and become dispositil
problems during the course of their confinement. T
patient role has been touted to promote dependent
Additional social biases expect less from the elde
and create the natural tendency to infantalize ther
Clinical management requires predictions about t)j
level of self-care the patient can hope to attain, ai
more than valiant attempts to maintain the function
ability they brought to the episode of illness. It b
comes a serious issue with strong ethical overtones
decide to intervene in a supportive manner and allc
decline. Maintaining the person’s strengths som
times may assume greater priority than resolution
the acute problem.
Patients need to maintain control over their liv
and daily living experiences. The comfort of beii
“taken care of’ is a luxury the aged can ill affoill
prematurely. A respite from the demands of life Cel
cause permanent decreased ability. In the best of sitij
ations, environment and routine should be adjusted
allow for full participation in living. Although tl
analogy is distasteful, many of the same environment
enrichments that have proved therapeutic for childre
might be employed with this population. Fumitur
toileting, and hygienic equipment should be placed ;
proper heights. Color-coded doors or pathways ca
mark the route to activity areas. Special space to kee
personal effects personalizes the environment an;
helps with identity maintenance. Readily availab
clocks, calendars, and other reminders of time an
place increase orientation. Large print books an
newspapers provide diversion, reality orientation, an
stave off the temptation to become too self-centered
One's normal patterns of living should be fostered, an
networks should be established to maintain ties to thl
community. Environmental enrichments and institi
tional policy adjustments are limited only by the exter
of our own creativity.
The configuration of a therapeutic program for th
acutely ill aged and the unique qualifications needej
to work in this environment justify special care unit
for these patients. The best manpower mix wouf
provide for primaiy health care nurses who are respon
sible for clinical care on an ongoing basis. Their acute:
ly developed skills of observation would allow immedi
ate intervention with subtle problems both related an<
unrelated to the primary condition which precipitated
the hospitalization. Additionally, there is need fo
clinical specialists in the areas of psychogerontology
restoration, and perhaps even additional specialty
areas, should the volume and case mix warrant. Ad
vanced skill in cardiovascular nursing, rheumatology
and pulmonary care may prove to be cost efficient. Ii
these days of emphasis on curtailing costs in acut<
care, and reimbursement on a case mix basis, complej
patients with an extended length of stay generate par
ticular attention. Many of these individuals are aged
Sophisticated nursing can decrease the length of stay
minimize the number of disposition problems, anc
increase the functional capacity of the elderly so they
can return to community living. Specialists in care o
656
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1 aged also can serve in a liaison capacity to other
x ts in the hospital who find they are servicing in-
casing numbers of aged.
> VIMARY
i <,ged persons in acute care hospitals deserve a
:! lical program and provider professionals who will
m tribute maximally to their recovery. An entirely dif-
< «nt mentality is called for in earing for the aged.
Hntenance of functional ability and decision-mak-
i prerogatives become essential to life. Mechanisms
i st be put into place to avoid the profound re-
» ssion which can accompany an acute episode of
l ess. Maintenance of physical, mental, and emo-
ihal ability in all their dimensions become priorities.
1 atever patterns were adequate and normal for the
agividual prior to admission should be maintained.
[ is may mean divorcing ourselves from eveiy
!
preconception of hospital routine. Creativity in the use
of support systems, hygiene activities, meals, and
sleep- rest patterns will all contribute to the total thera-
peutic effect. At all costs, life must be allowed to go on
as usual. Exquisite nursing assessment must allow us
to determine whether the patient should be cared for
within a model that aims to develop new self-care abili-
ty, maintain what exists, restore to a previous level of
functioning, or support what ability remains and ac-
cept inevitable decline. These decisions become very
difficult and hold ethical consequences. They should
be vested with the most sophisticated clinicians.
REFERENCES
1 . Carr C, Mezey M: Giving the hospitalized elderly the best
nursing care possible. Health Services Manager 104, 1982.
2. State of New Jersey, Department of Health: Case Mix
Nursing Performance Study. Trenton, NJ, 1979.
I
)L. 81— NUMBER 8— AUGUST 1984
657
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ONCE-DAILY
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
y
120
mg
'i
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL" LA brand of propranolol hydrochloride (Long Acting Capsules}
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and jgfltnewhat variable. INDERAL has
been shown to cause a small increase in serum potassii|jgj(concentration when usedijjthe
treatment of hypertensive patients. jp ™ _
In angina pectoris, propranolol generally reduces the oxygen requ»e8ienk>tt|iei3eai*at
any given level of effort by blocking the catecholamine-Indi^O^d inc^aSesin.the hqm'rate,
systolic blood pressure, and the velocity and extent of myobardial OQ ntractksB Propranolol
may increase oxygen requirements by increasing left yegtricalar fitj$r length end dpstolic
pressure and systolic election period The net phystGidgie effect ©f beta-adrenergic blockade
is usually advantageous and is manifested during exercise tty delayed ’dnsit of path and
increased work capacity. fjS
In dosages greater than required for beta blockade, INDERAL also exerts a quinidine-ljjff
or anesthetic-like membrane action which affects the, cardiac action potential. The-sig(#i-
cance of the membrane action in the treatment of anfiythmias. is uncertain, , 1 :
The mechanism of the antimigraine effect of pipprai.u u hn not been esfai?lishecr. Bdtp-
adrenergic receptors have been demonstrated in® plaf vessels df the brain
Beta receptor blockade can be useful in condftns in which, because of bathdkaflbr
functional changes, sympathetic activity is detrimental to the patient. But there are also
situations in which sympathetic stimulation is vital FoHlxamplerTn patients vtfflri severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension, it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL.
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible)
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonaliergic Bronchospasm (e.g,, chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking tf
prior to major surgery is controversial. It should be noted, however, that the impaired atf
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesli
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor ofl
receptor agonists and its effects can be reversed by administration of such agents)
dobutamine or isoproterenol. However, such patients may be subject to protracted <
hypotension. Difficulty in starting and maintaining the heartbeat has also been reportej
betj blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent th|
pearance of certain premonitory signs and symptoms (pulse rate and pressure changj
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be j
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroi!
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symi;
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have!
reported in which, after propranolol, the tachycardia was replaced by a severe bradyq
requiring a demand pacemaker. In one case this resulted after an initial dose of
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with imp
hepatic or renal function. INDERAL is not indicated for the treatment of hypertej.
emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pa
should be told that INDERAL may interfere with the glaucoma screening test Withdraws
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dis
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS; Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered The added catechola
blocking action may produce an excessive reduction of resting sympathetic nervous ai
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or ortho
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stud
both rats qgg rma^employiaadoses^Bytal 50 mg/kg/day, there was no evidence of sigm
drug-induced toxicity There were no drug-related tumorigenic effects at any of the dc
levels, Re(®ducj|$i§lBdies tn .ararmalsjpi not show any impairment of fertility thai
f attnbutabtefto the drug.
| ■ icy: fteglnancy Category C .INDERAL has been shown to be embryoto:
animal atflies at dosesaborff 10 times greater than the maximum recommended human i
There-are no -adequate and wefreOWfolled studies in pregnant women INDERAL si
be used during ^pnancy only if the potential benefit justifies the potential risk to the
Nursing Monts: INDERAL is excreted in human milk. Caution should be exercised
INDERAL, is administered to a nursing woman
Peiii®fric*U$e. Safety and effectiv^|(ss in children have not been established
ADVERSE REACTIONS, Moa%ad^se effects have been mild and transient and
rareiystAquired Ihe withdrawal of therapy
Cftfdiovasctflftf: i ' t^^gdi^^^raestive heart failure; intensification of AV block; t
jjjjensiol paresthesia Of hands thrombocytopenic purpura; arterial insufficiency, usually!
Raynaud type
Central Nervous Sys/emrfcghfheadedness; mental depression manifested by insoi
lassitude, weakness, fatigu ifdiiVersible mental depression progressing to catatonia; \
disturbances; hallucinations; an acute reversible syndrome characterized by disorientatir
time and place, short-term memory loss, emotional lability, slightly clouded sensorium
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diar
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with ac
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Hematologic : agranulocytosis, nonthrombocytopenic purpura, thrombocytop
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has i
reported.
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male n
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reac
involving the skin, serous membranes and conjunctivae reported for a beta blocker (prac
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride
sustained-release capsule for administration once daily. If patients are switched from INDE
tablets to INDERAL LA capsules, care should be taken to assure that the desired therap
effect is maintained INDERAL LA should not be considered a simple mg for mg substitu;
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitration
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inte
HYPERTENSION — Dosage must be individualized. The usual initial dosage is 8(
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage ma
increased to 120 mg once daily or higher until adequate blood-pressure control is achie
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage o
mg may be required. The time needed for full hypertensive response to a given dosae
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERA
once daily, dosage should be gradually increased at three to seven day intervals until optu
response is obtained Although individual patients may respond at any dosage level
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few wi
(see WARNINGS).
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDERAi
once daily. The usual effective dose range is 160-240 mg once daily The dosage mat,
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response ij
obtained within four to six weeks after reaching the maximum dose, INDERAL LA the]
should be discontinued It may be advisable to withdraw the drug gradually over a peric
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group are!
limited to permit adequate directions for use.
‘The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratc.
AYERST LABORATORIES
New York, N.Y. 10017
Ayerst
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE"
660
IrERIATRIC IMPERATIVE: SUMMARY
! TATEMENT OF ACP STUDY GROUP
IlCHAEL A. NEVINS, M.D., STEWART ALEXANDER, M.D., FRANCIS CHINARD, M.D.,
Edward Harris, m.d., Marven Wallen, m.d., woodcliff lake*
Community hospitals now should initiate positive actions to
mespond to the geriatric imperative. This workshop of the
Vew Jersey Chapter of the American College of Physicians
iffersfive guidelines for implementing a fresh approach to
lospital geriatrics.
The material collected at the
workshop of the American Col-
lege of Physicians-New Jersey
apter (ACP) was sufficiently compelling to warrant
p conclusion that community hospitals now should
titate positive actions to respond to the geriatric
perative. It is inappropriate to make broad gen-
ilizations about the quality of contemporaiy hospi-
geriatrics in this country. Yet, although the current
stem is satisfactory or improving in many respects,
;re is room for improvement.
rhe following generic comments are offered as guide-
es for implementing a fresh approach to hospital
riatrics:
* Old age is neither a diagnosis nor a prognosis,
ereotyping and labeling should be avoided. Many
tients of advanced age are independent, capable of
rticipating in the decision-making process referable
their care, and require no different treatment than
unger people. With advancing age, however, chronic
sabilities of sensation, mentation, continence, and
it increase substantially. Ward staffing and policy
ould reflect this fact. Ideally, there should be a match
tween patients’ needs and the level of service de-
ered; however, hospitals share with the health sys-
n in general a lack of sufficient alternatives to avoid
>quent mismatches.
• Care of the elderly should be oriented toward ill-
ss and global function rather than to specific dis-
eases. Thus, diagnostic tests should be pursued only
if they are likely to improve function or effect treat-
ment. While hospitals are good at curing disease, they
often pay too little attention to curing the patient. In
parallel to treating the admitting disorder, there
should be an overall assessment and early efforts
should be made to prevent functional deterioration.
• The nature of hospital geriatrics programs will
vary according to the special needs of individual in-
stitutions, but the concept of discrete geriatrics units
has been amply tested and validated and has become
normative in many countries. Such units can provide
an efficient mechanism of clustering of staff and
equipment as well as a means of expediting of specific
policy. They should not be warehouses for elderly pa-
tients suffering from terminal illness or a condition
from which reasonable rehabilitation is unlikely. The
“success” of geriatrics units depends substantially on
criteria for admission and whether the unit receives
patients from the onset of hospitalization or after the
acute illness has been corrected. Success depends also
upon the enthusiasm and morale of the staff. The team
concept is laudatory, but not easily accomplished and
much effort must be expended to assure the staff s
professional satisfaction.
’These five physicians are the Study Group of the American
College of Physicians; the Study Group met at a workshop at
MSNJ headquarters in May 1983.
)L. 81— NUMBER 8— AUGUST 1984
661
• The hospital is the natural focal point for all com-
munity health services directed to the elderly. A con-
tinuum of care must be provided so that short-term
gains are not wasted and community services coordi-
nated so as to keep patients at home and delay or avoid
institutionalization whenever possible. Also, it is
necessary to develop a closer articulation between
acute hospitals and long-term facilities. For example,
initiatives might be made to address the problem of
professional isolation of nursing home staff; hospitals
could take the lead via educational and consultative
outreach programs.
• The 1980s will be an era of stress for health in-
stitutions, but rather than becoming despondent be-
cause of limited resources, hospitals should respond
to the challenge and re-evaluate traditional policies.1
Many of the changes necessary for excellent geriatric
care involve altered thinking and attitudes rather than
costly new equipment.
Finally, this study group endorses the ten standards
for good health care for the aged proposed by the Sc
tish geriatrician D.C. Kennie,2 namely:
1. Emphasis on the restoration of functional abil ,
2. Building and maintaining a support system.
3. Broadened approach to health assessment.
4. Application of specific medical knowledge c\
skills.
5. Cautious medical intervention.
True advocacy for the patient.
Acceptance of the legitimacy of death.
Increased community orientation.
Allowance of sufficient time for recovery.
6.
7.
8.
9.
10. Continuity of care.
REFERENCES
1. Blendon RJ, Schramm CJ, Moloney TW, Rogers DE:
era of stress for health institutions. JAMA 245: 1843- If i
1981.
2. Kennie DC: Good health care for the aged. J/ ,
249:770-773, 1983.
1
I
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER! Y
662
Pharmacological Basis of Therapeutics:
jOSSYpol, an Oral Male Contraceptive?*
Stephen M. Penningroth. ph.d., piscataway**
Gossypol acts by inhibiting spermatogenesis , in particular by
impairing the motility of sperm. Its antispermatogenic effect is
reversible in many cases. Gossypol shows systemic toxicity at
high doses. More study is required before gossypol can be
approved for general use as an oral male contraceptive.
Women may choose among a vari-
ety of contraceptive strategies
including pharmacologic
lethods (estrogen/progestin combinations, vaginal
jDermicides, prostaglandins as abortifacients), a
lechanical barrier to conception (diaphragm), or
prgical sterilization. While a mechanical method (the
mdom) and surgical sterilization (vasectomy) are
/ailable to men, pharmacological contraceptive
rategies conspicuously are lacking. This dearth of
atifertility drugs for men springs from continuing
ignorance of many aspects of the cellular and
lolecular basis of male reproductive physiology. It is
iteresting to speculate on the historical and cultural
-irrents that have fostered intensive investigation of
iproduction in women and comparative neglect of
^production in men; however, this would lead far
field.
Chemical contraceptives for men can be divided into
yo general classes: 1) agents designed to inhibit
spermatogenesis by interfering with its endocrine
mtrol (androgens, estrogens, or progestins) — a major
rawback is that by inhibiting testosterone synthesis
hey suppress libido and potency: 2) agents which
lock spermatogenesis or the maturation of sperm in
ie epididymis— a major disadvantage is their
bxicity.1 A basic requirement for any male
antraceptive is virtual total efficacy in blocking sperm
motion, since survival of only a small number of the
hundreds of millions of sperm cells in the average
ejaculate may suffice for fertilization.
During the past decade, testing of an oral
contraceptive for men, gossypol, has begun. This
article summarizes current knowledge of the efficacy,
toxicity, and mechanism of antifertility action of this
potential new male contraceptive.
ISOLATE OF THE COTTON PLANT
Gossypol, a yellowish polyphenolic compound
isolated from the seeds, stem, and root of the cotton
plant, is known to be toxic at high doses. It is the
principal reason that cottonseed cake has not been
developed as a cheap protein source.2 Its male
contraceptive effect was discovered accidentally when
Chinese toxicologists investigated the cause of low
"This article, fourth in a series, prepared under the leadership
of Bruce McL. Breckenridge, M.D., Chairman, Department of
Pharmacology, UMDNJ-Rutgers Medical School, is a brief re-
view of recent advances in pharmacology and related
preclinical sciences which will help readers to understand the
actions of new and established therapeutic agents. The re-
views do not consider indications for specific drugs, incom-
patabilities, or dosage forms, which can be found in the AMA
Drug Evaluations. 5th Edition, 1983.
**Dr. Penningroth is an Assistant Professor, Department of
Pharmacology, UMDNJ-School of Osteopathic Medicine,
Piscataway. Correspondence may be addressed to Dr.
Breckenridge, UMDNJ-Rutgers Medical School, P.O. Box 101,
Piscataway, NJ 08854.
OL. 81— NUMBER 8— AUGUST 1984
663
fertility in a region of China where crude cottonseed
oil was used extensively in cooking. In 1978, the
National Coordinating Group on Male Antifertility
Agents (Peoples’ Republic of China) published the first
indepth study of the pharmacologic action and toxicity
of gossypol.3
TRIAL RESULTS FROM CHINA
Gossypol, 20 mg/day, was given to 4,000 healthy men
for periods of six months to four years. Infertility was
achieved in 99.89 percent of the subjects within two
months as judged by semen analysis demonstrating
necrospermia or a sperm count below 4 x 106 sperm/
ml. The proportion of motile sperm decreased and
the proportion of malformed sperm increased
progressively with gossypol treatment. Exfoliated
mono-, bi-, and multinucleated spermatocytes and
spermatids also were seen. Examination of damaged
sperm cells in the electron microscope revealed
disruption of the mitochondrial sheath, derangement
of the coarse axial fibers, and depletion of the
acrosome. With time, azoospermia ensued. When
gossypol was discontinued, the number and
morphology of sperm returned to normal within three
months, indicating reversibility. Side effects were
minimal: transient weakness at the start of drug
administration which subsided without treatment
(12.8 percent), and loss of libido but not potency (6
percent); recovery followed symptomatic treatment
without discontinuing gossypol, suggesting a
psychological reason for decreased libido. Levels of
serum testosterone and leuteinzing hormone (LH)
were normal. Hypokalemia was noted among subjects
in certain districts. However, hypokalemia is a general
medical problem in China today;21 thus the link
between gossypol and hypokalemia is tenuous.
Pharmacokinetic data from studies with rats indicated
gossypol is distributed principally in the liver, spleen,
lung, blood, kidney, and heart; significantly lower
concentrations are found in the testis, indicating the
antispermatogenic action of gossypol is testis-specific.
The discovery that gossypol
inhibits spermatogenesis in
men with minimal side
effects offers the possibility
of an oral contraceptive.
The findings reported by Chinese scientists
subsequently have been confirmed in their major
aspects and expanded. The absence of LH and
testosterone effects has been noted repeatedly,4 5
however, one study suggests gossypol inhibits
testosterone synthesis in isolated interstitial cells.6
The apparent lack of mutagenicity of gossypol has
been confirmed.78 Recent studies have indicated that
gossypol may have a beneficial hypolipidemic effect,9
and that also it inhibits catechol-O-methyltransferase,
a major enzyme in catecholamine catabolism. This
may prove to be a troublesome side effect in view of
the high concentration of gossypol attained in some
tissues.10
MECHANISM OF ACTION
The mechanism of action of gossypol current]
under investigation in several laboratories. L
functional parameter most sensitive to gossx
appears to be sperm motility.11 14 The first anatcf.
lesion that is observed by electron microscopy
i
segmental aplasia of the mitochondrial sheath of
sperm tail.11 This lesion does not occur until lat ii
sperm iogenesis (step 18). 12 13 It apparently induces *
dislocation of axial fibers observed in epididy A
sperm. The damage to the acrosome reported y,
Chinese workers has not been confirmed in ;b
sequent studies.1112 The seminiferous epithel r.
shows some damage consisting mainly of vacuola it
of Sertoli cells; however, this effect is highly focal n
volving less than 50 percent of the germinal )i
thelium. Interstitial (Leydig) cells are not affecteca
gossypol. 1 2
Possible molecular bases for the observed lesion j
sperm are enzymes that may be crucial to sperm i
differentiation. A sperm-specific isozyme of lac a
dehydrogenase, LDH-X, as well as acrosin, a prott *
found in the acrosome, are inhibited by gossypo i
vitro.1516 Gossypol also is known to uncouple oxida
phosphorylation.14 However, the relationship of tf
enzyme inhibitory effects to the antispermatogt
action of gossypol is not clear. Sperm flagellar (dyni
ATPase activity, which is crucial to motility, is
significantly inhibited.14 Finally, gossypol has b
shown to decrease testis weight in an animal mo
suggesting it may have an antiandrogenic effe<
Hovering over all studies of gossypol mechanism is
question of the possible role of gossypol metabolite
Two interesting effects of gossypol have been repor
which do not appear to be related to
antispermatogenic effect. Thus, gossypol inhibits
growth in culture of herpes simplex virus typ<
(responsible for genital herpes)18 and of Trypanoso
cruzi (responsible for Chagas’s disease).19
CONCLUSION
The discovery that gossypol effectively inhit
spermatogenesis in men with minimal side effe
offers the real possibility of an oral male contracept
However, the effects of gossypol may not be reversi
in all cases.20 Further, gossypol is known to be tc
at elevated doses. Thus, its therapeutic index may
quite narrow. The mechanism of action and poten r
toxicities of gossypol must be understood better bef
it can be approved as a safe contraceptive strategy
men. A welcome spinoff of further gossypol reseai
may be the stimulation of greater interest a
understanding the molecular and cellular basis of me
fertility.
REFERENCES
1. de Kretser DM: Towards a pill for men. Proc R Soc Lx d
B 195:161, 1976.
2. Lawrence SV: Gossypol: A potential male contracepti
Am Pharm 21:57, 198L
3. National Coordinating Group on Male Aniferti
Agents: Gossypol— -a new antifertility agent for males. C
Med J 4:417, 1978.
4. Shandilya L, Clarkson TB, Adams MR Lewis JC: Effejs
of gossypol on male eynomolgus monkeys (Macta
fascicularis). Biol Reprod 27:241, 1982.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSlf
664
3. Hoshai H, Uehara S, Mori R Nagaike F, Tsuiki A, Suzuki
Gossypol as oral contraceptive for male: Trial case report.
IhokuJ Exp Med 138:275, 1982.
|3. Lin T, Murono EP, Osterman J, Nankin HR Coulson PB:
' issypol inhibits testicular steroidogenesis. Fertil Steril
11:563, 1981.
7. de Peyster A, Wang YY: Gossypol-proposed contraceptive
,■ - men passes the Ames test. N Engl J Med 301:275, 1979.
1 3. Majumdar SK, Ingraham HJ, Prymowiez DA:
^ssypol— an effective male contraceptive was not mutagenic
• sperm head abnormality assay in mice. Can J Genet Cytol
^ 777, 1982.
1 9. Shandilya LN, Clarkson TB: Hypolipidemic effects of
ssypol in cynomolgus monkeys (Macaea Jascieularis).
%ids 17:285, 1982.
10. Tang F, Tsang AYF, Lee CP, Wong PYO: Inhibition of
ijteehol-O-methyltransferase by gossypol: The effect of
isma proteins. Contraception 26:515, 1982.
11. Oko R Hrudka F: Segmental aplasia of the
itochondrial sheath and sequelae induced by gossypol in
■ft spermatozoa Biol Reprod 26:183, 1982.
12. Hoffer AP: Effects of gossypol on the seminiferous
ithelium in the rat: A light and electron microscope study.
Biol Reprod 28:1007, 1983.
13. Oko R Hrudka F: Effect of gossypol on spermatozoa
Arch Androl 9(1):39, 1982.
14. Tso WW, Lee CS, Tso MYW: Effect of gossypol on boar
spermatozoal adenosine triphosphate metabolism. Arch
Androl 9:319, 1982.
15. Lee CYG, Moon YS, Yuan JH, Chen AF: Enzyme
inactivation and inhibition by gossypol. Mol Cell Biochem
47:65, 1982.
16. Tso WW, Lee CS: Gossypol: An effective acrosin blocker.
Arch Androl 8:143, 1982.
17. Lee CY, Moon YS, Duleba A, Chan AF: The instability
of gossypol. Arch Androl 9(1):33, 1982.
1 8. Wichman R Vaheri A Juukkainen T: Inhibiting herpes
simplex virus type 2 infection in human epithelial cells by
gossypol, a potent spermicidal and contraceptive agent. Am
J Obstet Gynecol 142:593, 1982.
19. Montamat EE, Bungos C, de Bungos NMG, Roval LR
Blanco A Inhibitoiy action of gossypol on enzymes and
growth of Trypanosoma cruzi. Science 218:288, 1982.
20. Guo-Zhen L: Double-blind study of gossypol: The
loading phase. Arch Androl 9(1):38, 1982.
21. Bardin CW: Personal communication.
if
!
;)
I
I
4
i
(
9L. 81— NUMBER 8— AUGUST 1984
665
More people have survived cancer than
now live in the City of Los Angeles.
We are winning.
Please support the
V Ml\ERKm CANCER SOCIETY
§
666
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS)
e Impaired Physicians Program
Another Kind of Impairment
Edward G. Reading, m.div., lawrenceville*
There are many kinds of impairment The Impaired Physicians
Program of the Medical Society of New Jersey is here for your use ,
so tap the resources of this special program.
enerally speaking, impairment
H among physicians is considered
to exist when the physician is
revented from functioning at a professional level due
) chemical use or dependency or problems with men-
d health or physical disability. While these are the
rimary categories of impairment dealt with by the
npaired Physicians Program, we now are able to
lentify another category of impairment which
reviously has been all but lost in a sea of confusion.
Physicians can be prevented from peak functioning
/hen their minds are not on their work because of
imily members or “significant others” who are
hemically dependent or who themselves have emo-
ional or physical problems. One of the issues frequent-
V recognized in the literature on addictionology is
ailed the “family disease” of chemical dependency,
his issue goes far beyond that of biological heredity,
it is involved with the relationships which develop be-
ween a chemically dependent person and those who
tave an “emotional investment” in them. Most often
hese are family members. The Impaired Physicians
Program has tried to emphasize the necessity of family
nembers being in treatment with the physician who
3 chemically dependent.
'ASE EXAMPLE 1
Dr. S is living with his family in an urban communi-
y with his wife and three children. The youngest child
is 1 6 and has become involved in alcohol abuse, as well
as suspected marijuana use. There are more frequent
incidents of coming home intoxicated on weekday
nights. Recently, when Mrs. S confronted the adoles-
cent about the drinking and suspected other drug use,
the 16 year old became violent and pushed her against
the stove, scalding her with boiling water. Dr. and Mrs.
S are not able to control the situation. The other two
children are veiy successful in college. Dr. S treated his
wife for the bums and has had to cancel patient ap-
pointments due to loss of sleep at night, appointments
with school officials, and anxiety caused by the high
degree of stress in the household. With his mind on
the home front, he has not been as attuned to his
patients’ needs as he should be.
Recently, a parent came to him to seek advice on how
to handle a similar problem with her child. He gave
advice; advice which he was not accepting for himself.
Now he feels guilty and embarrassed over his own
situation. Dr. S is impaired. He needs assistance in
dealing with his problem, for his own sake, his family,
and his patients. He can use the assistance of the
Impaired Physicians Program.
CASE EXAMPLE 2
Dr. J is a resident at a suburban hospital. She was
Rev. Reading is Assistant Director, Impaired Physicians Pro-
gram, MSNJ.
VOL. 81— NUMBER 8— AUGUST 1984
667
called by the police in her mother’s community and
told that they picked up her 62-year-old mother walk-
ing aimlessly on the highway, unable to remember her
name, where she was coming from, or where she was
going. Dr. J, being an only child and single, decided to
take her mother into her home to care for her. Dr. J
constantly is being called at the hospital by her mother
and by neighbors describing strange happenings
around the house. Due to the influence these events
have had on her job performance, she has had two
warnings to ‘‘shape up or ship out.”
Dr. J is impaired. She is not dealing effectively with
her mother’s disabling condition. She can use the as-
sistance of the Impaired Physicians Program.
CASE EXAMPLE 3
Dr. C’s wife is an adult child of two alcoholic parents
who died when she was 15. She is a veiy insecure
person who tries to be in control of the situation at
all times. Mrs. C had a psychotic breakdown which
caused her to be admitted to a psychiatric hospital.
The C’s children “blame” Dr. C for causing the break-
down. Dr. C is not able to function effectively in his
practice. He is impaired. He needs help in dealing with
his situation at home. He can use the Impaired Phy-
sicians Program.
CASE EXAMPLE 4
John is a third-year medical student. His father is
an alcoholic lawyer who is in danger of losing his prac-
668
tice, as well as his family and friends. John has h|
to leave school periodically to return home to “pick i
the pieces” after a drinking bout. John’s mother is v<|
embarrassed about “the neighbors finding out.” Jo
is missing so much class time that he is in danger
being thrown out of school. The high degree of stni
that the family is experiencing is causing John
begin some drug use of his own. John’s father neei
help, and so does John. This family can use the I
paired Physicians Program.
CONCLUSION
The Family Services component of our Program c
help the physicians in these situations. Additiona
we can help families of chemically dependent phy
cians get into their own recovery program. We c
assist in helping physicians in our Program “talk
their children” (if it is appropriate) about their o\
disease.
There are many kinds of impairment. There r
many resources, frequently unknown to the impair
physician and his family. For every type of impairme ;
there is a way to effectively deal with it. It may
difficult but it always is easier to deal with diffici
situations with help from concerned, caring p:
fessionals, than to try to handle it alone.
If you are in such a situation, or know of a physicij
who is, please call (609) 896-1766 and tap the
sources here for your use.
j
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
Your Congressman Speaks:
The Cost of Health Care
Congressman Jim Courier*
There is a need to find reforms that can introduce
competitive forces into the market for medical care without
imposing excessive burdens on the individual or reducing the
quality of care.
H
It is a great honor for me to ac-
cept The Academy of Medicine
of New Jersey Citizen’s Award
r 1984. 1 am extremely gratified to receive your recog-
tion for the work that the people of my district have
iscted me to perform. The Academy of Medicine of New
■rsey also is deserving of recognition and praise, for
ie more than 70 years of work you have done to
Ivance the cause of quality health care for the people
New Jersey.
I would like to take a few moments to discuss the
sue of organ transplants before I get to the main
pic of my talk. It has been several years now since
argeon-General Everett Koop, liver transplant
tecialist Dr. Tom Starzl, and I got together to discuss
lie widespread use of organ transplant surgery and
ie mind-boggling implications of the immunity-sup-
'essing drug, cyclosporine A. Since that time, there
as been a surge in public awareness of the great
mefits of this surgical technique, and this publicity
as helped save the lives of a number of young trans-
ant patients.
But, while science rapidly has improved the effective-
's of organ transplants, the nation’s system for re-
ieving organs has failed to keep pace. Advances in
edical science have expanded transplant needs to
iclude several organs, yet a national procurement sys-
m exists only for kidneys. Of the 20,000 persons who
tffer brain death that could result in organ donations
ich year, fewer than 15 percent actually result in
JL. 81— NUMBER 8— AUGUST 1984
donations. This occurs despite a 1982 Gallup poll
which showed that 72 percent of those persons
surveyed said they would give permission to have cer-
tain organs of a loved one donated after death. To
compound the problem, transplant surgery still is con-
sidered “experimental” by many health insurers. As a
result, patients whose health plans won’t cover organ
transplants are denied the surgery because they can-
not finance the large down payments required by hos-
pitals.
In view of these problems, it gives me great pleasure
to tell you that in the near future, the House of Rep-
resentatives will consider the “National Organ Trans-
plant Act.” This comprehensive bill will improve
retrievement through establishment of organ procure-
ment organizations, as well as a U.S. Transplant
Network to help distribution of organs nationwide. The
bill also will help patients and their families with the
expenses involved in transplant operations by requir-
ing the U.S. Department of Health and Human Services
to purchase and supply patients with the immunosup-
pressive drugs that are essential for successful trans-
plants. This legislation should pave the way for even
greater participation in transplantation by the medical
profession and private medical insurers. I urge you to
give the measure your attention and support.
‘Congressman Jim Courter represents the 12th District of
New Jersey and is a member of the Select Committee on
Aging. This talk was presented at The Academy of Medicine
of New Jersey Annual Dinner.
669
The main topic I would like to address tonight is the
rising cost of health care, and some of the approaches
being discussed in Washington to deal with this situ-
ation.
It cannot be denied that the cost of health care is
increasing dramatically, and has continued to increase
above the general rate of inflation in the economy. In
1965, 6 percent of our gross national product (GNP)
was consumed by health care expenditures— in 1982,
that figure was 10.5 percent of GNP. There has been
a dramatic growth of the federal government’s expen-
diture on health care. The combined cost of the Medi-
care and Medicaid programs, which was $3.9 billion
in 1967, reached $64 billion in 1982, and is projected
to reach $100 billion by 1986.
Before we consider measures that government might
take to lessen this growth, we first must determine to
what extent the rising cost of medical care is a problem
that calls for a federal government solution. Certainly,
a significant portion of the money we spend on health
care has paid for new services and technologies which
were not available a few years or a few decades ago.
You know this far better than I do— as you look
around at your work environment, you see all kinds
of new tools of the medical profession that have
brought dramatic qualitative improvements to the
menu of health care services available to the average
American. The CAT scanner, bum units, coronary in-
tensive care units, and shock-trauma centers are but
a few examples of recent, high-technology improve-
ments that have expanded your diagnostic and healing
powers, and saved lives.
We all would prefer that new medical technologies
would cost less, but there are few in our society who
would argue that they are not worth having because
they may be veiy expensive.
In fact, many of the reforms discussed during the
1970s such as national health insurance and hospital
cost containment were defeated, for a very good reason:
it was feared that these reforms would cut costs by
rationing health care and reducing the availability of
promising new methods of treatment.
So, before Washington sets out to save America from
rising medical expenses, it should observe the great
dictum: “If it isn’t broke, don’t fix it.” There is nothing
inherently wrong with paying more for a higher quality
service. It would be a terrible mistake to reform the
economics of medicine in a way that would reduce the
quality of the greatest health care delivery system in
the world.
However, there are steps that can be taken to control
the cost of health care. To illustrate the type of reform
I have in mind, I would like to use an example from
a field where I do have some expertise — the field of
defense.
I am sure you all have seen the press reports of
exorbitant prices paid by the Department of Defense
for simple goods and spare parts. This situation was
discovered by the Pentagon’s own auditors and in-
vestigators, and reforms are being made to prevent this
kind of waste in the future. But how did this ever come
about? How could anyone be so foolish as to pay $100
for a simple diode, or more than $690 for a 50-cent
metal washer? The answer is simple. The consumer
did not know what goods were being bought for wh
price. Supply officers who authorized payment sj
numbers on a computer screen— some represent
prices, some represented symbols for the goods— ai
there was no warning, nor any incentive system, whii
caused these discrepancies to be discovered. In oth
words, the consumer was insulated from the cruc
information he needed to make a sound jud
ment — the information on the cost of the goods he w
buying.
To a large degree, the consumer of health care
America is in a similar situation — he is insulated frc
the cost of the service he buys, because bills are pa
by third parties, such as the government, the employ
or the insurance company. The incentive to sh<
around and to compare prices and services largely
absent in health care even though market incentiv
serve us so well in every other sector of the econorr
We need to find some reforms that can introdu
competitive forces into the market for medical ca
without imposing excessive burdens on individuals
reducing the care available to the needy in our sociei
While many of the Reagan Administration’s a
pointees were proponents of pro-competition refom
in health care, a few years passed before the Admini
tration put forward a set of actual legislative proposa
to accomplish this goal. Now that these proposals a
on the table, they deserve serious consideration ar
discussion by all of us who have an interest in mail
taining affordable, high-quality health care in Americ
One proposal would place a modest cap on the t<
exemption given to employer-financed health ii
surance. This cap would be designed to prevent tl
type of overinsurance which unnecessarily can drf
up utilization rates and costs.
Another administration proposal would requi
modest copayments by patients for Medicare rein
bursements for inpatient hospital care. This would ac|
to the incentive for outpatient treatment and reducei
hospital stays, and it would generate funds that coul'
pay for catastrophic coverage under Medicare.
A third proposal would create a Medicare vouch<
program to encourage consumers to save monr
through more economical alternative private healt
insurance programs.
Taken together, these proposals seek to reform th
health care system by increasing consumer awarenes
of medical costs and services. They are modest an
responsible and they will provide incentives for r<J
duced cost without depriving any member of societ
of needed medical care. Above all, they are far superic
to the proposals of previous administrations, whic
would have increased government involvement an
regulation and would have reduced the availability c
quality medical care.
It is unfortunate, in my opinion, that Congress ha
given these sound proposals so little attention sine;
they were introduced. There is little prospect that Conj
gress will act on them this year, so we will have to wai
until next year’s session of Congress before any actioi
can be taken. When that time comes, I hope that thes
proposals will receive the careful consideration an<
support of the medical profession.
670
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
: r the Investigation of
Problems of Human Infertility
le Foundation provides a complete
Agnostic and consultation service for in-
tile couples. Investigations are con-
cted by well-known specialists in con-
nction with consultants in the various
Ids of medicine related to infertility.
.e Foundation is supported by an in-
fuse modern laboratory equipped to do
Dst tests required for diagnosis and
jatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jersey. This special issue
illuminates the beginnings of our health care system and the growth of medical
care: essays highlight those talented individuals who devoted themselves to this
system, and commentaries present the development of specialized care in as-
sociated fields of medicine. Plus a special photography section highlighting three
statewide exhibits.
Copies of this issue are available by sending $5.00 (check or money order)
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648. All MSNJ members will
receive one copy of this issue.
Name
Address
Enclose a $ 5.00 check or money order for each copy.
The Academy of Medicine of New Jersey
presents
Original Limited
Edition Print
Mercer Oak
by Richard Kemble, $40
For more inforrriation, call 896-1717
PUBLIC RELATIONS
for physicians and surgeons with a medical specialty.
Please call for a confidential conversation with an ex-
perienced professional.
Seymour F. Malkin Public Relations
Phone 201-666-4400
651 Colonial Boulevard
Washington Township
Westwood P.O., New Jersey 07675
, 81— NUMBER 8— AUGUST 1984
671
DOCTORS’
NOTEBOOK
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
The University has been making
major strides in two fields that con-
cern the medical profession in New
Jersey: cancer treatment and re-
search, and biotechnology research.
The Center for Molecular Medi-
cine and Immunology on our New-
ark campus, which officially was
opened on June 13, is devoted ex-
clusively to the use of monoclonal
antibody “tracer bullets” to detect
cancer. CMMI’s president, David M.
Goldenberg, Sc.D., M.D., is the van-
guard of investigators using mono-
clonal antibodies to diagnose cancer
earlier and more accurately and to
locate cancer more accurately in the
body. Patients have come long dis-
tances from within the country and
from overseas for CMMI diagnosis.
CMMI has increased the clinical
resources, scientific base, and repu-
tation of the University’s cancer pro-
grams, providing new opportunities
for New Jersey patients and medical
students, as well as to the cancer
research and cancer care programs
of the entire region. As Michael
Bongiovanni, chairman of Squibb
Medical Products, said at the CMMI
dedication, no state is more dedi-
cated to health education, research,
and care than the state of New Jer-
sey.
As part of that dedication, we re-
cruited Dr. Goldenberg and his re-
search team from the University of
Kentucky more than a year ago. The
present staff of 25 scientists and
support personnel is expected to
grow to 80. The opening of CMMI,
which has initial funding of $3.45
million, symbolizes the start of an
entirely new phase of New Jersey’s
battle against cancer.
On another front, biotechnology
research, progress is being assisted
by state grants totaling $717,800 for
state-of-the-art equipment. Among
equipment to be purchased are two
DNA synthesizers, a cell-sorter, and
nuclear magnetic resonance spec-
trometer (NMR). These devices are
essential for the creation and pro-
duction of new biomaterials that
may be used for purposes ranging
from cancer treatment to the de-
struction of toxic waste.
More than half of the money —
$332,800— will be concentrated on
buying equipment for the Center for
Advanced Biotechnology and Medi-
cine, whose establishment was a
high priority recommendation of the
Governor’s Commission on Science
and Technology, on which I serve.
Satellite facilities of the
biotechnology center will include
Middlesex General-University Hospi-
tal in New Brunswick, core teaching
affiliate of UMDNJ-Rutgers Medical
School, and the Waksman Institute
of Microbiology, part of Rutgers Uni-
versity. Norman H. Edelman, M.D.,
associate dean for research at
UMDNJ-Rutgers Medical School,
earlier was named acting director of
the center, which is to be adminis-
tered jointly by UMDNJ and Rutgers
University on the Piscataway cam-
pus.
UMDNJ-New Jersey Medical
School in Newark received $75,000
from the state biotechnology grant
total. That money will go toward
purchasing a DNA synthesizer and
computer analysis system for DNA
studies directed by Giampiero di
Mayorca, M.D., chairman of the de-
partment of microbiology. Ad-
ditional funds are being sought to
meet the total equipment cost of
$131,000.
The line between unwarranted
fear of environmental canc
dangers and exposures which cc
stitute a real threat is difficult
the lay public to distinguish.
The Department of Environmt
tal and Community Medicine
UMDNJ-Rutgers Medical School
using a $75,000 grant from t
Exxon Foundation to develop
model program for getting the lat<
information on environmental a
industrial chemicals to the pub
Codirectors of the project ;
Michael Gochfeld, M.D, Ph.
clinical associate professor, a
Audrey Gotsch, D.P.H., assists!
professor and director of the depai
ment’s Office of Consumer Hea
Protection.
The University is a constar
changing scene of new faces a
new places to serve patient ca
medical education, and resear'
Among recent changes are thes<
John W. (Jack) Bingham, an
perienced New Jersey hospital ;
ministrator, has joined UMDNJ-U
versity Hospital in Newark as cf
operating officer. Jack came
UMDNJ from the Hackensack Me
cal Center, where he worked ei£
years and was senior vice-presidi
and director of hospital operatio
Before that he was associate direc
at the Jersey City Medical Cent(
Stanley J. Robboy, M.D, an int
nationally recognized patholog
has accepted the appointment
professor and chairman, deps
ment of pathology, and UMDNJ-N
Jersey Medical School. Dr. Robb:
who comes to us from the Haiv<
Medical School faculty, is not
among other accomplishments,
research into DES, the synthe
hormonal preparation linked
cancer in women whose mothi|
had taken it, and in the use of co
puters in medical management a
information systems.
The Cognitive Rehabilitation Pi
gram of UMDNJ-Rutgers Medii
School has been renamed T
Center for Cognitive Rehabilitatii
and moved from the PiscataV
campus to 97 Bayard St. in N'
Brunswick. Directed by Irwin
Pollack, M.D., professor of psychia
at UMDNJ-Rutgers Medical Schh
the center offers therapy to peo!
who have suffered traumatic br;i
injury from accident, infection, s r
gery, or stroke, and whose ability >
think and act in an orderly mam '
has been damaged.
672
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
SNJ Auxiliary
ace Ge liman
;sident
The 1984 to 1985 officers of the
>NJ Auxiliary were installed by
s. John Bates, AMA Auxiliary
"Sident on May 5, 1984, during
i? Annual Meeting at Resorts Inter-
tional, Atlantic City,
chairmen have been appointed
■d the proposed program for the
ning year will be presented to the
•dical Society of New Jersey for ap-
pval.
/our Auxiliary sent seven del-
ates to the AMA Auxiliary Annual
ssion. We were so proud to see our
n Mrs. James Brennan installed
treasurer of the AMA Auxiliaiy by
past-president, Mrs. Harry
Dvorsky. I was honored to be invited
to be in the receiving line at the
Medical Society of New Jersey’s re-
ception at the Chicago Marriott
when Karl T. Franzoni, M.D., and
Arthur Bernstein, M.D., were pres-
ented for AMA Councils on Medical
Services and Scientific Affairs, re-
spectively.
While in Chicago, Mrs. Charles
Moloney and I had an opportunity to
meet with John Moore, Assistant
Professor of Communication Arts at
Loyola University. He will present
the annual Workshop Program of
the MSNJ Auxiliary in Lawrenceville
on September 24th. His subject is
“Avenues Leading to Personal Suc-
cess: Ingredients for Self-As-
surance.” All members of the Medi-
cal Society and the Auxiliary are en-
couraged to attend.
We had attended Professor
Moore’s seminar at last year’s Lead-
ership Confluence in Chicago and
were impressed by his dynamic
presentation. It was a real learning
experience.
New Members
The Journal would like to welcome
the following new members to the
Medical Society of New Jersey:
Atlantic County
Fernando J. Delasotta, M.D., Somers
Point
Vithal D. Kardani, M.D., Atlantic City
Bergen County
Frank C. Arturi, M.D., Cliffside Park
Roger H. Coletti, M.D., Oakland
Lynda A Farrell, M.D., Oakland
Sundararamaiah Ganti, M.D., Englewood
Digvijay S. Gimar, M.D., Hackensack
Robert M. Israel, M.D., Westwood
Donald Liss, M.D., Englewood
Howard Liss, M.D., Englewood
Gregory A Pappas, M.D., Fort Lee
Almerindo G. Portfolio, Jr., M.D.,
Ridgewood
Donald C. Syracuse, M.D., Belleville
Morris A Tilson, M.D., Fair Lawn
Drew E. Tuckman, M.D., Fair Lawn
Shirley Tung, M.D., Fort Lee
Kenneth H. Wasserman, M.D., Englewood
Joseph H. Willner, M.D., Englewood
Camden County
Shwu-Miin Yang Chen, M.D., Cincinnati,
Ohio
Robert H. Gerard, M.D., Blackwood
Mark S. Isserman, M.D., Voorhees
Mark A Macklis, M.D., Camden
William A Morowitz, M.D., Blackwood
Andrew S. Olearchyk, M.D., Audubon
Lolita M. Ramos, M.D., Voorhees
Robert M. Williams, M.D., Bellmawr
Essex County
Terence J. Aheme, M.D., Roseland
Ricardo Alzadon, M.D., Irvington
Uma Ananthapadmanabha, M.D.,
Bloomfield
Ruby G. Bendersky, M.D., Millbum
El Ballesteros Castro, M.D., Newark
Vincent C. Giampapa, M.D., Belleville
C. Clayton Griffin, M.D., Newark
David J. Jacobs, M.D., Short Hills
Walter J. Molofsky, M.D., Newark
Arnold Schonmuller, M.D., Newark
Carlos R Vargas, M.D., Newark
Daniel Zacharias, M.D., Maplewood
Gloucester County
Howard H. Buxbaum, M.D., Swedesboro
Dong Sup Cha, M.D., Woodbury
Eileen M. Moynihan, M.D., Haddon
Heights
Robert J. Terranova, D.O., Sewell
Hudson County
Tomas J. Barrios, M.D., Union City
Rosa M. Gonzalez, M.D., West New York
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jer-
sey. This special issue illuminates the beginnings of our
health care system and the growth of medical care: essays
highlight those talented individuals who devoted themselves
to this system, and commentaries present the development
of specialized care in associated fields of medicine. Plus a
special photography section highlighting three statewide
exhibits.
Copies of this issue are available by sending $5.00
(check or money order) to MSNJ, Two Princess Road, Law-
renceville, NJ 08648. All MSNJ members will receive one copy
of this issue.
Name
Address
Enclose a $5.00 check or money order for each copy.
>L.
81— NUMBER 8— AUGUST 1984
673
Munir AAeQ. Hasan, M.D., Jersey City
Sophie H. Pierog, M.D., Jersey City
Deborah H. Wozniak, M.D., Bayonne
Hunterdon County
Paul P. Madura, Jr., M.D., Hampton
Kevin K. Mooney, M.D., Ringoes
David V. Nenna M.D., Flemington
Mercer County
Lauri D. Ervin, M.D., Princeton
Bartley A Larsen, M.D., Lawrenceville
Bruce L. Safman, M.D., Lawrenceville
Floyd Weinstock, M.D., Lawrenceville
Middlesex County
Fazlur R Panezai, M.D., Edison
Matthew H. Smith, M.D., Iselin
Monmouth County
Saroj Dhamija, M.D., Middletown
Barry L. Swiek, M.D., Long Branch
Morris County
Natalie I. Bilenki, M.D., Whippany
Donald J. Billmaier, M.D., Morristown
Mark A Bronstein, M.D., Morristown
Michael M. Danber, M.D., Boonton
Ilene M. Hershman, M.D., Morristown
Lawrence W. Raymond, M.D., Florham
Park
Sadhana S. Sathe, M.D., Morristown
Clifford A Taylor, M.D., Morristown
Ocean County
Tun-Sang Chu, M.D., Toms River
Peter J. DeMuro, D.O., Jackson
Samuel D. Schenker, M.D., Lakewood
Passaic County
Ashoke Agarwal, M.D., Totowa
Michael P. Basista, M.D., Clifton
Duncan B. Carpenter, M.D., Fair Lawn
Timothy J. Droney, M.D., Upper
Montclair
Edwin P. Kane, M.D., Clifton
Oscar A. Reicher, M.D., Wayne
Mark Wiesen, M.D., Clifton
Somerset County
Thomas J. Nordstrom, M.D., Bridgewater
Stephen M. Ocken, M.D., Somerville
Union County
Elizabeth W. Hill, Berkeley Heights
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ALCOHOLISM — George W. Miller, Jr„
M.D., 77 Grove St., Apt. 8, Montclair, NJ
07042. UMDNJ 1980. Available
ALLERGY/IMMUNOLOGY— Leonard
Bielory, M.D., 688 Concerto La., Silver
Spring, MD 20901. UMDNJ 1980.
Board eligible. Solo preferred, but flex-
ible. Available March 1985.
T.M. Bokhari, M.D., 48 Anderson Pkwy.,
Cedar Grove, NJ 07009. FJMC. Also in-
fectious diseases (pediatric). Board
certified (PED). Group, partnership,
solo. Available.
ANESTHESIOLOGY— Cau Pham, M.D.,
856 Nelson, Apt. 206, Chicago, IL
60657. Saigon (South Vietnam) 1974.
Group or partnership. Available.
RS. Saraiya, M.D., 88-25A 153rd St„
Apt. 4-F, Jamaica, NY 11432. Baroda
(India) 1978. Group or partnership.
Available.
FAMILY MEDICINE — Laurence
Levenberg, M.D., 63 Harrowgate Dr.,
Cheriy Hill, NJ 08003. SUNY-Upstate
1966. Group, partnership, solo. Avail-
able.
GASTROENTEROLOGY— Harry D
Buraek, M.D., 5548 Waterman PL, St.
Louis, MO 63112. Albany 1978. Also
internal medicine. Board certified.
Partnership, group, solo. Available.
Prakash V. Huded, M.D., 80-15 41 Ave„
Apt. 606, Elmhurst, NY 11373.
Kamatak (India) 1970. Board certified.
Solo, group, partnership. Available.
ILL. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Board
eligible. Also, internal medicine. Part-
nership, group, full-time hospital.
Available.
Neil Tarkin, M.D., 6700 192nd St„
Fresh Meadows, NY 11365. New York
Medical 1978. Also, internal medicine.
Board certified (IM). Any type practice.
Available.
Mark F. Tsai, M.D., 1715 Stanford Dr.,
Columbia, MO 65201. National Taiwan
University 1977. Also, internal medi-
cine. Board certified. Available.
GENERAL MEDICINE — John J. Kim,
M.D., 127 Garfield Ave., Jersey City, NJ
07305. Catholic Medical College
(Korea) 1966. Group, partnership, solo.
Available.
INTERNAL MEDICINE— Harry D
Buraek, M.D., 5548 Waterman PI., St.
Louis, MO 63112. Albany 1978. Also
gastroenterology. Board certified. Part-
nership, group, solo. Available.
Z.UA Farooqui, M.D., Plaza Pro-
fessional Bldg., Bayshore Rd. and
Greenwood Ave., Box 238, Villas, NJ
08251. Aurangabad Medical College
(India) 1972. Board eligible. Group or
partnership. Available.
Aditi Gupta, M.D., 27 Sturbridge Dr.
West, Piseataway, NJ 08854. Lady
Hardinge (India) 1980. Board eligible.
Clinie/hospital or group. Available.
Lee W. Hoffer, M.D., 1017 E. 80th St.,
Brooklyn, NY 11236. Rome (Italy) 1980.
Solo, partnership, group. Available.
H.L. Kirschenbaum, M.D., 780 Woolley
Ave., Staten Island, NY 10314. New
York Medical College 1977. Boa
eligible. Also, gastroenterology. Pai
nership, group, full-time hospit
Available.
Quang T. Nguyen, M.D., 15 '
Englewood Ave., Bergenfield, NJ 0765
Saigon (South Vietnam) 196
Subspecialty, nephrology. Boa
eligible. Any type practice. Available
Claudia Anne Pollet, M.D., 61
Parkway Dr„ Baltimore, MD 2121
Mount Sinai 1981. Board eligib
Salaried position in emergency rooi
clinic, or urgent care center. Availab
Paul V. Renda, M.D., 3206 Myra S
Apt. D, Durham, NC 27707. Mou
Sinai 1981. Board eligible. Solo, grou
clinic (preferably southern NJ). Ava
able.
Richard B. Schwarz, M.D., 8300 E,
Longpre Ave., Apt. 204, Los Angeles, (
90069. NYU 1979. Subspeciali
nephrology. Board certified. Groi
HMO, hospital. Available.
Gopal Shah, M.D., 100 Caton Ave., A]
2-G, Brooklyn, NY 1 1218. M.R Medic;
College (India) 1976. Board eligib
Group. Available.
Neil Tarkin, M.D., 6700 192nd S
Fresh Meadows, NY 11365. New Yo
Medical 1978. Also, internal medicir
Board certified (IM). Any type practii
Available.
Steven Wolinsky, M.D., 1404 E. 15 S
Brooklyn, NY 1 1230. Case Western F
serve 1980. Group or partnersh
Available.
NEPHROLOGY— Quang T Nguyen, M.
15 W. Englewood Ave., Bergenfield, i
07621. Saigon (South Vietnam) 1 9€
Also, internal medicine. Board eligit
Any type practice. Available.
Richard B. Schwarz, M.D., 8300 E
Longpre Ave., Apt. 204, Los Angeles, (
90069. NYU 1979. Also, internal met
cine. Board certified (IM). Group, HM
hospital. Available.
OBSTETRICS / GYNECOLOGY— Balwa
K. Chhatwal, M.D., 6416 Fairfield Av
Berwyn, IL 60402. Delhi (India) 197
Group, partnership, solo. Available.
Sheela Choubey, M.D., 1 Zirkel Av
Piseataway, NJ 08854. Poona (Ind;
1977. Board eligible. Group or partnt
ship. Available.
Edwin R Guzman, M.D., 1200 E. 98
St„ Brooklyn, NY 1 1 236. New Yo
Medical 1980. Board eligible. Group
partnership. Available Septemb
1984.
AtuI S. Sheth, M.D., 2951 S. King t
Chicago, IL60616. T.N. Medical Colle
(India) 1972. Specializing in infertili
reproductive endocrinology. Boa
eligible. Partnership, single or multif
group practice, academia. Available.
Ernest A. Topran, M.D., 3523 De'
beriy-Southem Oaks, Shreveport, 1
71118. Louisiana State 1980. Group
partnership. Available.
OCCUPATIONAL MEDICINE— Err
Emmet Vernon, M.D., 2018 Pickerti
Dr„ Deer Park, TX 77536. University
674
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
he West Indies (Jamaica) 1978. Board
ligible. Group. Available.
DIATRICS — Dorothea H. Gross, M.D.,
:64 Boonton Turnpike, Lincoln Park,
JJ 07035. Geneva (Switzerland) 1950.
Jinic, group, emergency room, hospi-
al, pharmaceutical research (salaried),
jwailable.
Jusumam Sidharthan, M.D., 222
"orkshire Ct„ Old Bridge, NJ 08857.
j)alicut Medical College (India) 1976.
jloard eligible. Available.
BIOLOGY/ NUCLEAR MEDICINE—
^onrad P. Erlich, M.D., 1243 Beacon
>t„ Apt. 3B, Brookline, MA 02146. Bos-
on 1976. Board certified. Group or
Partnership. Available.
/Iindy M. Horrow, M.D., 131 Pond
Brook Rd., Chestnut Hill, MA 02167.
Jedical College of Pennsylvania 1980.
board eligible. Group, HMO, academia.
Wailable.
Bubhash S. Pujara, M.D., Box 39 IB, Rt.
1, Andalusia, AL 36420. B.J. Medical
College (India) 1969. Board certified
radiology); board eligible (nuclear
nedicine). Group, partnership, solo.
Wailable.
RGERY, GENERAL— Sara A. Case,
4.D., 284 Quinby Rd., Rochester, NY
4623. Virginia 1975. Board eligible,
iroup — general surgery in moderate-
iized city. Available.
Wiben J. Delgado, M.D., 7514 Oriental
/r„ San Antonio, TX 78244. Puerto
lieo 1976. Also, vascular surgery.
Board certified. Single or multi-
ipecialty group or solo. Available,
.eonardo A. Garduno, M.D., 2170 S.
Boebbert Rd., Apt. 1-109, Arlington
leights, IL 60005. University of the
Bast (Philippines) 1968. Any type prac-
ice. Available.
Barry Jordan, M.D., 260 Garth Rd.,
Bcarsdale, NY 10583. South Carolina
977. Board eligible. Group, partner-
;hip, solo. Available.
I. Bernard LeSage, M.D., P.O. Box 699,
Jiddlesboro, KY 40965. Montreal
Canada) 1945. Board certified. Admin-
strative medicine. Available,
lames M. Stem, M.D., 600 Vista Court,
Vaynesboro, PA 17268. Jefferson
.958. Board certified. Solo, with free-
lorn to practice in broad spectrum of
iurgery, including vascular and frac-
ures. Available.
iRGERY, ORTHOPEDIC — S.N.
Baraiya M.D., 88-125A 153rd St., Apt.
1-F, Jamaica NY 1 1432. Baroda (India)
;974. Solo. Available.
[RGERY, VASCULAR— Ruben J.
Belgado, M.D., 7514 Oriental Tr., San
Witonio, TX 78244. Puerto Rico 1976.
\lso, general surgery. Board certified
GS). Single or multispecialty group or
solo. Available.
tOLOGY — Kiritkumar M. Pandya,
4.D., 950 49th St., Apt. 9-A, Brooklyn,
W 11219. Baroda (India) 1970. Board
‘ligible. Group, partnership, solo. Avail-
ible.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
\
\
I
I
LIPONICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPONICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
( BRO'M'5fc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 1PDR
ARE YOU A SAINT MICHAEL’S ALUMNUS?
Saint Michael’s Medical Center, Newark, NJ, a 117 year old
teaching hospital, is forming a medical alumni association. We
are seeking some 5,000 physicians who served as residents
and interns. Over the years many of our former house staff
members have relocated making consistant communication
difficult.
Our alumni association will be oriented towards four goals:
professional, medical, social and educational. Plans are
already being made for a medical reunion dinner and sym-
posium in the fall.
If you are a former member of Saint Michael’s house staff or
know another staffer’s whereabouts,
877-5494 or write to:
SAINT MICHAEL S MEDICAL CENTER
268 Dr. Martin Luther King, Jr. Blvd.
Newark, NJ 07102
attn: Office of Public Affairs
please call (201)
7th ANNUAL CURRENT CONCERNS IN ADOLESCE!
MEDICINE — “A PRACTITIONERS GUIDE T
TEENAGE HEALTH CARE”— October 25 & 26, 19(
The Warwick Hotel, New York, NY. Sponsored tj
Division of Adolescent Medicine, Department of Pei
atrics, Schneider Children’s Hospital, Long Island Je
ish-Hillside Medical Center, New Hyde Park, NY. Topi
include: Communicating with the Teenage Patient a
Family; Hematological Problems; Anorexia Nervo;
Diabetes in Adolescents; Common Infections in Adok
cents; Gynecology for the Practitioner; Sexually Trar
mitted Diseases; Recognizing Depression; Abdomir
Pain; Sports Evaluation and more. Credits 12 Categc
1 from the ACCME and AMA. Information: Ann
Boehme, Continuing Education Coordinator, Lo
Island Jewish-Hillside Medical Center, New Hyde Pai
NY 11042, (212) 470-2114.
The Journal of the Medical Society of New Jersey
announces the reprinting of the
i
WILLIAM CARLOS WILLIAMS
COMMEMORATIVE ISSUE
September, 1983
Honoring the 100th anniversary of the birth of New Jersey’s prize-winning poet and physician.
Included in this handsomely illustrated, full-color issue will be original articles by persons
close to William Carlos Williams, artwork from his social and intellectual circle, and samples
of his finest writings.
Copies of this special issue are available by sending $5.00 for each (check or money order)j
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648.
Please send a copy of the William Carlos Williams Commemorative Issue to:
Enclose a $5.00 check or money order for each copy.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS/
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
Sept. 9-11, 1984 and again the weekend of Oct. 26-28, 1984 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
office journal, Acupuncture & Electro-Therap. Res., Int.J. (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Research
Foundation and the Neuroscience Dept, of Long Island College
Hospital, Pharmacology Dept, of The Chicago Medical School.
Also eligible for AMA/CME credit. For information, contact Y.
Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC 10032. Tel:
(212) 781-6262 or (212) WA8-0658, or Saul Heller, M.D., Tel:
(212) 838-7514.
676
ME Calendar
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
is list is compiled through the coop-
ition of the Committee on Medical
ucation of the Medical Society of New
rsey. The Academy of Medicine of
w Jersey, the New Jersey Chapter of
; American Academy of Family Phy-
ians, and the Office of Continuing
;dical Education of the UMDNJ. For
urination on accreditation, please
ntact the sponsoring organization(s),
iicated by italics— last line of each
m.
lRDIOLOGY
pt.
Advanced Cardiac Life Support-
Provider
'I 7:00 P.M. — Helene Fuld School of
Nursing, Camden
(West Jersey Health System and
AMNJ)
:t.
Calcium and Cardiovascular
Function
1 :30-5:30 P.M. —Drew University,
Madison
(Drew University, CIBA-Geigy
Pharmaceutical Division, and
AMNJ)
! Pharmacological Treatment of
p Cardiovascular Diseases
8:30 AM. -5: 1 5 P.M. —Resorts
International, Atlantic City
(UMDNJ and AMNJ)
MEDICINE
Sept.
6 Evaluation and Assessment of the
Allergic Child
9 AM. — Freehold Area Hospital
(AMNJ)
1 3 Mammography and Minimal
Breast Cancer
7:45-9 P.M. —Burlington County
Memorial Hospital, Mount Holly
(Burlington County Medical
Society and AMNJ)
19 Dermatological Conference
6-9 P.M. — Rutgers Community
Health Plan, U.S. Hwy #1 and Rt.
18, New Brunswick
(UMDNJ -Rutgers Medical School)
20 Ontogeny of the Immune System
27 Immune Responses and
Regulation
4-6 P.M. — Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
20 Advances in Pain Management
8 AM. -5 P.M. — Resorts
International, Atlantic City
(UMDNJ and AMNJ)
2 1 Bronchial Asthma-Current
Concepts of Management
9 AM. — St. Francis Medical Center,
Trenton
(St. Francis Medical Center)
Oct.
3 Venom Therapy
8-9:30 P.M. —The Manor, West
Orange
(NJ Allergy Society and AMNJ)
4 Immunoregulation: Basic
1 1 Concepts and Applications
18 4-6 P.M. — Institute for Medical
25 Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
5 Treatment of Acute Hypertension
19 Headache
9 AM — St. Francis Medical Center,
Trenton
(St Francis Medical Center)
10 Nephrotic Syndrome
17 Leukemias in the Adult
31 Pulmonary Rehabilitation
1-2:30 P.M. — VA Medical Center,
Bldg. 93, Lyons
(VA Medical Center and AMNJ)
1 1 Medical Update: Use of Thyroid
Function Tests
12 noon-1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
13 Hyperthermia for Cancer
8:30 AM. -5 P.M. — Medical Society of
New Jersey, Lawrenceville
(AMNJ)
17 Dermatological Conference
6-9 P.M. —Rutgers Community
Health Plan, U.S. Hwy ** 1 and Rt.
18, New Brunswick
(UMDNJ-Rutgers Medical School)
24 Regional CME Meeting, ACP and
NJSIM
9 AM. -4 P.M — Landmark Inn,
Woodbridge
(American College of Physicians
(New Jersey) and New Jersey
Society of Internal Medicine)
27 Basic and Practical EKG Course
8:30 A.M. -6 P.M. — Sheraton Heights
Hotel, Hasbrouck Heights
(Palisades General Hospital and
AMNJ)
30 AIDS in Children
7- 9 P.M — Englewood Hospital
Learning Center, Englewood
(Englewood Hospital and AMNJ)
NEUROLOGY/PSYCHIATRY
Sept.
5 Computer and Clinical Psychiatry
9: 1 5 AM. -4:45 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
6 Late Onset Schizophrenia
13 Depression: Current Management
and Future Directions
20 Social Management of Breast
Cancer and Surgery
12 noon- 1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 2 The New Antidepressants
1-2:30 P.M. —Bldg. 93, VA Medical
Center, Lyons
(VA Medical Center and AMNJ)
19 Cognitive Rehabilitation in a
Geriatric Medical Center
8:30 AM. -4 P.M.— Bldg. 93, VA
Medical Center, Lyons
(VA Medical Center and AMNJ)
20 Symposium — New Frontiers in
21 Cognitive Rehabilitation
22 All day— Hyatt Regency, Princeton
(Robert Wood Johnson, Jr.
Lifestyle Institute and Natl. Head
Injury Foundation)
20 The Yarmulka in Dreams
8- 10 P.M — Hackensack Hospital
(NJ Psychoanalytic Society and
AMNJ)
Oct.
4 Research Update: Aging, The
Elderly, and E.C.T.
12 noon-1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 9 The State of Psychiatry for 1984
8:30-10:30 P.M. — Coachman Inn,
Cranford
(NJ Psychiatric Association and
AMNJ)
23 Alzheimer’s Disease
24 9:15 AM. -4:45 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
PEDIATRICS
Sept.
1 1 Pediatricians’ Perspective of
Language Development
9:30-10:30 A.M. —Elizabeth General
Medical Center, Elizabeth
(Newark Beth Israel Medical
Center and AMNJ)
)L. 81— NUMBER 8— AUGUST 1984
677
FIFTH ANNUAL MEDICOLEGAL SEMINAR
Wednesday, September 12, 1984
8:30 a.m.- 4:00 p.m.
Medical Society of New Jersey Executive Offices
Two Princess Road
Lawrenceville, NJ 08648
presented by
Medical Inter-Insurance
Exchange of New Jersey
Department of Risk Management
Afternoon Session
12:00 Lunch
12:45 “Medical Malpractice; The
View from the Chair”
James S. Todd, M.D.
Chairman, Board of MIIENJ
1:00 “The Professional Liability
World Today; The State of
the Industry”
Peter Sweetland, President,
MIIENJ
1:45 “The Claim Climate in New
Jersey; A History and a
Look at the Future”
Joseph DeRoma, Vice-President,
Claims, MIIENJ
2:30 “An Ounce of Prevention;
Causes of Suits and Programs
Developed To Avoid Them”
Adam P. Wilczek, Director,
Department of Risk Management,
MIIENJ
3:15 Questions and Answers
DETACH AND MAIL TO MSNJ, TWO PRINCESS ROAD, LAWRENCEVILLE, NJ 08648
Enclosed is my check for payable to MSNJ
NAME (PLEASE PRINT)
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERJ'’
APPROVED FOR 5% CME CATEGORY I CREDITS
REGISTRATION
PLEASE RESPOND NO LATER THAN AUGUST 31, 1984
NO REFUNDS AFTER SEPTEMBER 10, 1984
MSNJ MEMBER OR MIIENJ INSURED $10.00
NON MSNJ MEMBER OR 25.00
NOT INSURED WITH MIIENJ
Medical Society of New Jersey
Department of Professional
Liability Control
Morning Session
8:30 Registration and Coffee
9:00 Greetings
Frank Y. Watson, M.D., President,
MSNJ and James S. Todd, M.D.,
Chairman of the Board, MIIENJ
9:20 Opening Remarks
James E. George, M.D., J.D.,
Director, Department of Professional
Liability Control
9:45 “The Snitch Bills; Their Impact
on Medical Malpractice”
Vincent A. Maressa,
Executive Director, MSNJ
10:15 “Reporting of Medical Malpractice To
State Board of Medical Examiners”
Floyd J. Donahue, M.D., Member of State
Board of Medical Examiners
10:45 “The New Case Management and
Procedures of Malpractice Litigation”
Honorable Peter Ciolino, Assignment Judge
Superior Court, Passaic County
11:15 Questions and Answers
678
lDIOLOGY
pt.
Mammography and Minimal
Breast Cancer
7:45-9 P.M.— Burlington County
Memorial Hospital, Mount Holly
(Burlington County Medical
Society and AMNJ)
Nuclear Magnetic Resonance
12 noon— St. Mary’s Hospital,
Orange
(AMNJ)
RGERY
pt.
Infectious Complications of
Trauma
8 A.M.-4 P.M. — NJ Medical School,
Rm. B-552, Newark
(UMDNJ and AMNJ)
Thoraco-Abdominal Aneurysm
5:15-6:15 P.M. — Shores Memorial
Hospital, Somers Point
(Shore Memorial Hospital and
AMNJ)
25 Regional Isolation Perfusion
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
Medicine / Psychiatry
9: 1 5 A.M.-4:45 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
12 Medicolegal Seminar
8:30 A.M.-4 P.M.— Medical Society of
New Jersey, Lawrenceville
(Medical Inter Insurance
Exchange of NJ, MSNJ, and AMNJ)
17 Ethnic Patterns in Health Care
1-4 P.M. —Saint Barnabas Medical
Center, Livingston
(Fair Oaks Hospital, Saint
Barnabas Medical Center, and
AMNJ)
19 CME Workshop
9 A.M.-4 P.M. — MSNJ Executive
Offices, Lawrenceville
(MSNJ and AMNJ)
Oct.
18 Nurse as Expert Witness in Court
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
SURGICAL SPECIALTIES
Sept.
20 Thoraco-Abdominal Aneurysm
5:15-6:15 P.M. — Shore Memorial
Hospital, Somers Point
(Shore Memorial Hospital and
AMNJ)
Oct.
23 Ophthalmology Update
1984-1985
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
MISCELLANEOUS
Sept.
5 Computers in
WE ARE SPECIALISTS
in
PUBLIC RELATIONS
and
MARKETING
FOR THE MEDICAL PROFESSION
for a confidential interview call
(201) 531-7080
v / phyllis kessel associates
780 West Park Avenue, Oakhurst, NJ 07755
)L. 81— NUMBER 8— AUGUST 1984
679
ifs Not What You Know,
It’s How You Record It.
Most busy
physicians
find continuing
medical education,
credits easier to
collect than
to remember.
So the Academy
of Medicine of
New Jersey is offer-
ing an easy system
for recording and reporting
CME credits for AMA recognition
as well as Medical Society and
professional organization membership.
A computerized CME recordkeeping
system is available to every New Jersey
physician. All you do is send us a
reporting card (which your office staff can
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membership requirements.
Mail to: Academy of Medicine of New Jersey, 2 Princess Road, Lawrenceville, NJ 08648
680
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
[STTERS TO THE
IOITOR
Comments on the Williams
Issue; DRGs—Two View-
points; Fulcrums and
Forums and Clout; Mass for
Physicians
omments on the
llliams Issue
April 30, 1984
?ar Doctor Krosnick
Your William Carlos Williams
)mmemorative Issue (September
183) is an auric treasure of educa-
mal and inspirational material. I
and the article “William Carlos
illiams and Charles Demuth” es-
:cially valuable.
Figure 1 of that article shows
larles Demuth’s 1928 painting “I
iw The Figure 5 in Gold,” from the
fred Stieglitz Collection (1949) at
ie Metropolitan Museum of Art.
ie painting is based on Williams’s
>em ‘The Great Figure.” Your read-
's may be interested to know that
is dynamic painting appeared as
ie cover illustration for the Janu-
y 2, 1981, issue of JAMA accom-
mied by an eloquent essay on De-
uth and Williams by M. Therese
^uthgate, M.D.
Dr. Southgate points out (among
other observations in this cover
stoiy) the painting’s multiple refer-
ences to William Carlos Williams’s
appellations and avocations, as well
as the “visual Doppler effect” of the
golden figure 5.
In the same issue, an auto-
biographical comment by Robert
Coles, M.D., ‘William Carlos Wil-
liams: A Writing Physician,” closed
with these golden words: “The doc-
tor as writer. The writer as ironic
self-observer. The observer as, still,
teacher to all of us — medical stu-
dents and physicians and men and
women everywhere, and in each gen-
eration, who crave beauty: the sight
of it, the sound of it.”
(signed) Steven R Kohn, M.D.
DRGs—Two
Viewpoints
May 22, 1984
Dear Doctor Krosnick:
I take exception to Vincent
Maressa's article in the May 1984
issue of The Journal of the Medical
Society of New Jersey (pages
409-410) as it represents, once
again, tunnel vision on the part of
the political hierarchy of the medical
profession. Our leadership opposed
Social Security, Blue Cross and Blue
Shield, Medicare, and now DRG. If
we had volunteered and gotten in on
the “ground floor,” less time and ef-
fort on our part would be needed
now to iron out the “kinks” in the
DRG system. DRG is here to stay. Dr.
Bernard Rineberg is correct in call-
ing for “true cooperation” (page 408)
and this is what the public expects
and demands of the medical pro-
fession. When will we ever learn?
(signed) Gerald E. Rubaeky, M.D.
June 6, 1984
Dear Doctor Krosnick
Thank you for the opportunity to
respond to Dr. Rubacky’s letter.
This broad and sweeping refer-
ence to historical opposition of the
medical profession to Social Secur-
ity, Blue Cross and Blue Shield,
Medicare, and now DRG, is absolute-
ly inaccurate.
Medical leadership did not oppose
the concept of Social Security for the
general population, but did oppose
mandatory participation of self-em-
ployed persons.
Medicine organized, formed, and
sponsored Blue Cross and Blue
Shield. I can find no creditable refer-
ence regarding opposition.
Medicine did not oppose Medicare
for the needy. It did oppose universal
Medicare and pointed out it would
be terribly expensive and create ex-
cessive demand (res ipsa loquitur).
Medicine declared DRGs to be ex-
perimental and unproved. Medicine
demanded scientific investigation of
the cost effectiveness and quality of
care issues of DRG before they be-
came mandated. The government
did not listen. Defects should be re-
moved before the craft is airborne.
Question: Why is it valid to oppose
governmental policy on Vietnam, the
Middle East, Central America, the
economy, and the environment, but
wrong to oppose misguided gov-
ernmental policy on health and
health economies?
Vincent A Maressa
Executive Director, MSNJ
Fulcrums and Forums
and Clout
May 24, 1984
Dear Doctor Krosnick
At the 1984 meeting of the Medi-
cal Society of New Jersey, a list of the
26 recognized “specialty societies”
was evidenced. For a specialty so-
ciety to have representation beyond
recognition in MSNJ, 80 percent of
its members must be members of
the Medical Society of New Jersey. It
is disturbing to see that of the 26
groups, exactly half have qualified
for representation. I am sorry to see
that my own group, the New Jersey
State Society of Anesthesiologists is
among the missing.
Having been observing our prob-
lems for some 50 years, I still am
distressed at some of our members
who are 1) indifferent, 2) take no
action at all, or 3) picket outside the
pale of influence. No matter how
much you are for or against some-
thing, your leverage is not effective
unless you can apply it at a fulcrum.
That fulcrum is where push and
shove meet, and is found in the
forum provided by the Medical So-
ciety of New Jersey in our House of
Delegates. If you want to be heard,
you must have “voice," and voice is
translated as “presence.” That pres-
ence means that when you give voice
you are seen and heard as one ac-
DL. 81 -NUMBER 8— AUGUST 1984
681
lively participating, and not as
someone rudely aroused from medi-
cal slumbers by a prospective
financial pinch or an aborted privi-
lege. The world is still full of two
kinds of people, the ones who work,
and the ones content to let them. We
solicit your active participation,
(signed) Edward G. Bourns, M.D.
Mass for Physicians
May 30, 1984
Dear Doctor Krosnick:
Bishop McCarrick will celebrate
the second annual Mass for phy-
sicians and medical personnel at St.
Francis Cathedral, Main Street,
Metuchen on Sunday, October 14,
1984, at 12 noon.
This is an opportunity for the
Bishop to express his gratitude to
all members of the medical pro-
fession and to offer them his sup-
port and prayers.
I would ask you, as Editor of The
Journal of the Medical Society of
New Jersey, to publish an an-
nouncement and invitation to your
I
constituents. We also would ;.i
preciate your good judgment i.
using other means of communic-
ing this information. Hoping to :*
many medical personnel on Oetolr
14, I am
Faithfully yours in Chr ;
(signed) (Rev.) Joseph L. Desmoij
Secretaiy to the Bishi
Diocese of Metuchj
Coordinator of Heai
Care Apostoh
682
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
OOK REVIEWS
itlas of Cross-Sectional
inatomy; Clinician's
ipproach to Endocrine
*roblems; Controversies in
)ermatology; Guide to
Cardiology ; Nelson's
' extbook of Pediatrics;
'echnological Basis of
ladiation Therapy
tlas of Human Cross-
ectional Anatomy
maid R. Cahill, Ph.D., and Mat-
ew J. Orland, M.D. Philadelphia,
i, Lea & Febiger, 1984. Illustrated.
k 139. ($29.50)
This book is an atlas of the human
dy in cross-sectional study. The
ctions were prepared by freezing
d sectioning, immediately photo-
aphed to preserve anatomic rela-
inships, and then fixed and dis-
cted. Orientation drawings eon-
niently show the level of each cut.
The atlas is divided into body re-
ms, with separate sections of the
nale pelvis. Each photograph has
ndamental features labeled, and
e accompanying drawing of the
sseeted section is labeled ex-
nsively.
The authors note that this work
so includes many soft tissue de-
ils which may not be evident on
e various clinical imaging studies
irrently available, but may be of
latomie or pathologic interest.
This atlas should be in the library
every radiographic department or
fice that does C-T scanning or
milar cross-sectional studies.
Joseph Peyser, M.D.
Clinician’s Approach to
Endocrine Problems: 45
Case Studies
C.R. Kannan, M.D. Chicago, IL, Year
Book Medical Publishers, Inc., 1983.
Pp. 514. ($29.95)
This book presents 45 endocrine
case studies, each dealing with an
individual patient with a chief com-
plaint, history, and physical examin-
ation, followed by clinical questions,
laboratory and procedure, results,
and therapy. After each case the
author discusses answers to ques-
tions with the end result being a
very satisfactory learning experience
for each topic discussed.
The ease topics are varied and in-
clude types of Cushing’s syndrome,
hyperaldosteronism, pheo, AGS,
prolactinoma various associated en-
docrinopathies, DI, inappropriate
ADH, various thyroid syndromes,
diabetic syndromes, amenorrhea
male endocrine syndrome, preco-
cious puberty, Z-E syndrome, and
hyperlipidemia
The text is very informative and
draws from reference material
quoted at the conclusion of each
case presentation. Some important
values are that the text brings what
has been established in research
and laboratory endocrinology to its
manner of use in clinical daily case
handling and decision making, and
allows the reader to compare
methods of diagnosis and therapy.
Finally, the discussion justifies the
ordered systematic selection of
procedures in arriving at the
diagnosis. The differential diagnosis
is presented nicely with a good dis-
cussion of what can be ruled in or
out. The methods of suggested
diagnostic procedure are detailed,
with results followed by a quoted
range of included norms.
There is a very good method of
presentation of selected endocrine
cases for the student of clinical en-
docrinology.
Mark M. Singer, M.D.
Controversies in
Dermatology
Ervin Epstein, M.D. Philadelphia,
PA W.B. Saunders Company, 1984.
Pp. 482. Illustrated. ($55)
This book represents a group of
subjects in the field of dermatology
which are considered as worthy of
assembling one or more opinions by
current investigators and author-
practitioners. Some of the con-
troversy does not appear in the text
itself, since the editor indicates that
a number of potential contributors
did not feel there was need for any-
thing further to be written, other
than the accepted knowledge in the
medical literature or their specific
course of management of a con-
dition.
There are a total of 14 sections in
the book and each is well written by
the numerous contributors. The edi-
tor generally has a comment — his
own or a reflection on the opinions
of the authors — at the end of the sec-
tions and completes his page with a
terse, “Think it over.”
Controversies in Dermatology is a
hardcover book, but I would not con-
sider it to be a textbook; it is more
of a philosophical discussion on
most of the subjects considered or
adjudged to be controversial, insofar
as the editor is concerned. It is quite
up to date and it would be apropos
in an academic medical library,
rather than as an addition to one’s
personal collection.
Murray Kahn, M.D.
The Guide to Cardiology
Robert A. Kloner. M.D., (ed). New
York, NY, John Wiley & Sons, 1984.
Pp. 624. Illustrated. ($29.95)
This book on cardiology contains
most of the important ingredients of
the specialty presented in a clear
and practical manner by a group of
28 authors and the editor, FLA.
Kloner. It begins in the usual
fashion with descriptions of elec-
trocardiography, cardiac physiology,
and cardiac radiology. This type of
introductory material is found in
almost all of the numerous cardiac
texts, so the better creative represen-
tation of the subject comes in later
chapters.
Arteriosclerotic heart disease with
its manifestations of angina, cor-
onary spasm, stenosis, myocardial
infarction and heart failure, diag-
nosis, and treatment are well
handled. There are chapters on peri-
cardial disease, infective en-
docarditis, cardiac tumor, hyper-
tension, and hyperlipidemia.
Pulmonaiy embolus and pul-
monary hypertension have a chapter
but I would have liked more on cor
pulmonale, a disease most often
3L. 81— NUMBER 8— AUGUST 1984
683
seen in the aging population with
chronic obstructive pulmonary dis-
ease.
There is even a good discussion of
noncardiac surgeiy in the cardiac as
well as cardiopulmonaiy resusci-
tation.
The large number of contributors
does not make the text redundant or
overlapping, apparently due to the
careful work of the editor.
This book is meaty, precise, and
practical — ideally suited for the
cardiac clerk, intern, resident, and
medical practitioner. Surgeons
might find it a handy guide when
faced with a cardiac problem.
If you do not have a good complete
up-to-date cardiac text, go out and
buy this one.
Manuel J. Rowen, M.D.
Nelson’s Textbook of
Pediatrics , 12th Edition
Richard E. Behrman M.D., and Vic-
tor C. Vaughan III, M.D., (eds).
Philadelphia, PA W.B. Saunders
Company, 1983. Pp. 1,899. Il-
lustrated. ($75)
This text, one of the two classical
single-volume American texts of
general pediatrics, has come out in
a new edition which, in my opinion,
is satisfactory justification for the
expense involved. While no one
agrees with everything, a random
sample of articles on topics about
which I felt comfortable yielded a
high percentage of concurrence with
my own experience and knowledge
of the literature. The index, which in
past editions has not always been as
comprehensive as I would like,
seems to have improved. There are
many veiy useful tables and flow
charts.
Avrum L. Katcher, M.D.
Technological Basis of
Radiation Therapy:
Practical Clinical
Applications
Seymour H. Levitt M.D., and Norah
duV. Tapley, M.D. Philadelphia, PA,
Lea & Febiger, 1984. Pp. 336. Il-
lustrated. ($45)
This excellent text on the “how to”
of radiation therapy is the compan-
ion book to Dr. Gilbert H. Fletcher’s
classic Textbook of Radiation Ther-
apy, which for many years has been
the bible to most radiation on-
cologists. Each chapter is written by
different well-known experts in their
fields and the overall quality of their
presentations is superb. AlthoujE
we may differ with some of the d!
tails of the methods of therapy, sin
one’s experience may favor a d
ferent approach, in general the d
scriptions of the methodology a
detailed, well-illustrated, and full
useful and practical information
which many therapists will be refe
ring on a daily basis in their tree
ment planning.
A listing of some of the subjects
the chapters will indicate the flavi
of this book: rationale for treatmei
planning, treatment aids for e
temal beam radiotherapy, cornph
field arrangements, dosimetry, inte
stitial techniques, iridium ter
plates, and the use of compute
tomography in treatment plannin
Irradiation techniques for trea
ment of neoplasms of the head ar
neck, lung and esophagus, brai
gynecologic system, breast, prostat
testes, urinary bladder, an
lymphatic system are well describe
I predict that this book will be o
every radiation oncologist’s bool
shelf next to Dr. Fletcher’s tome an
will be well worn and thumbe
through in short order as become
any useful classic. This book is re
ommended to all radiologists an
residents who practice radiatio
therapy.
Sidney Ketyer, M.l
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEV
684
BITUARIES
l
~)rs. Abel; Bump; Byck;
leVivo; Dickinson; Fischer;
lardam; Good; Hitzemann;
Juhasz; LaPorta; Myers;
?oss; White; and Willoughby
i
|
!jr. Henri E. Abel
V senior member of the Union
'unty Medical Society, Henri
Jest Abel, M.D., died on May 11,
34. Bom in Elizabeth in 1899, Dr.
liel received his medical degree at
'mell University’s Medical School
i 1924. He began his career as a
’ leral practitioner, but in 1945, Dr.
iiel began specializing in derma-
<bgy, and in 1963, he and three of
) children, formed the Elizabeth
- rmatology Group. He retired from
ijive practice in 1981, having been
i Mated with Elizabeth General
Sbpital over 30 years. Dr. Abel had
>n chief of staff for 3 years, had
>'n president of the New Jersey
• "matological Society, and had
•lived his county medical society
) h as president and treasurer. Dr.
Ijfel was a member of the American
^dical Association.
V'L. 81— NUMBER 8— AUGUST 1984
Dr. S. Calthrop Bump
S. Calthrop Bump, M.D., a member
of our Bergen County component,
died on May 5, 1 984. A native of Syr-
acuse, New York, bom in 1906, Dr.
Calthrop received his medical degree
at the University of Rochester’s
School of Medicine in 1935. He
specialized in orthopedic and trau-
matic surgery, and had been direc-
tor of that specialty at The Valley
Hospital, Ridgewood. Dr. Bump also
served as chairman of the medical
board and chairman of the surgical
control, disaster, and records com-
mittees at the hospital. In addition,
he donated much of his free time to
the Cerebral Palsy Center in Ridge-
wood. Dr. Bump was a Fellow of the
American College of Surgeons as
well as the International College of
Surgeons, and a member of the
American Medical Association.
Dr. Louis Byck
We just have learned of the death
in October 1983 of Louis Byck, M.D.,
formerly a member of the Essex
County component, and residing in
Santa Rosa, California. A native of
Philadelphia, bom at the turn of the
century. Dr. Byck was graduated
from Columbia University's College
of Physicians and Surgeons in 1925.
Specializing in allergies, he estab-
lished a practice in East Orange, and
had been affiliated with Newark
Beth Israel Medical Center. Dr. Byck
was a member of the American
Medical Association. He had been a
recipient in 1975 of MSNJ’s Golden
Merit Award in recognition of his 50
years of medicine.
Dr. John A. DeVivo
A senior member of our Essex
County component, John Americo
DeVivo, M.D., died March 14 at the
Veterans Administration Medical
Center, East Orange. A native of
Newark, Dr. DeVivo earned his medi-
cal degree at Georgetown University
in 1934. Prior to his retirement in
1973, Dr. DeVivo was a surgeon in
his hometown and had been af-
filiated with City Hospital and the
Lutheran Hospital, Newark. He had
served in the medical corps of the
Army of the United States during
World War II, attaining the rank of
captain. Dr. DeVivo, a member of the
American Medical Association, was
75 years old at the time of his death.
Dr. DeVivo posthumously was
awarded Golden Merit recognition
by MSNJ at this year’s Annual Meet-
ing.
Dr. George W. Dickinson
We just have learned of the death
on November 15, 1983, of George
Wallace Dickinson, M.D., formerly a
member of the Burlington County
component. A native of Arkansas,
bom in 1902, Dr. Dickinson was
graduated from the University of Ar-
kansas School of Medicine in 1929.
Dr. Dickinson practiced family
medicine in Palymyra until 1974
when he returned to his home state
where he established a clinic in
DeQueen, Arkansas. In 1979, Dr.
Dickinson was granted MSNJ’s
Golden Merit Award in honor of his
50 years of medical practice.
Dr. Alvin L. Fischer
At the untimely age of 56, Alvin L.
Fischer, M.D., a member of our
Union County component, died on
May 20, 1984. Bom in New York
City, Dr. Fischer received his medi-
cal degree from the University of
Lausanne’s Faculty of Medicine,
Switzerland, in 1958. He specialized
in obstetrics and gynecology in
Elizabeth, and was affiliated with
both Saint Elizabeth and Elizabeth
General Hospitals. Dr. Fischer was
board certified in his specialty.
Dr. Joseph W. Gar dam
An internist for over 50 years in
Newark, Joseph William Card am,
M.D., died in Riverview Medical
Center, Red Bank, on May 7, 1984.
Bom in Brooklyn, Dr. Gardam re-
ceived his medical degree from New
York Medical College in 1916. He
had been affiliated with Saint
Barnabas Medical Center, Liv-
ingston, and also had worked in the
Newark Health Department, in
charge of the communicable disease
division. He was board certified in
internal medicine-cardiovascular
diseases, and was a Fellow of the
American College of Physicians. He
had been a member of the American
Medical Association, and in 1966,
Dr. Gardam was a recipient of
MSNJ’s Golden Merit Award, honor-
ing his 50 years of practice. Dr. Gar-
685
dam was 88 years old at the time of
his death.
Dr. Charles K. Good
Charles Kemm Good, M.D., a der-
matologist in Union City, died at his
home on May 1, 1984. Bom in Jersey
City, Dr. Good was graduated from
Cornell University Medical College in
1929. He was affiliated with Christ
Hospital, Jersey City, and the Skin
and Cancer Clinic in New York City.
Dr. Good was a Fellow of the Ameri-
can Academy of Dermatology and a
Fellow of the New York Academy of
Medicine, as well as being board
certified in his specialty. He also was
a member of the American Medical
Association. Dr. Good received
MSNJ’s Golden Merit Award in 1979
marking his 50 years in medicine.
Dr. Louis A. Hitzemann
A senior member of our Bergen
County component, Louis Anthony
Hitzemann, M.D., died on May 20,
1984. Bom in Missouri at the turn
of the centuiy. Dr. Hitzemann ob-
tained his medical degree from St.
Louis University in 1925. He estab-
lished his practice in Hackensack,
specializing in medical problems of
the eye, ear, nose, and throat. He was
affiliated with Holy Name Hospital,
Teaneek and the Eye and Ear In-
firmary, Newark. Dr. Hitzemann was
board certified in otolaryngology,
and a Fellow of the American
Academy of Ophthalmology and
Otolaryngology. He was honored
with MSNJ’s Golden Merit Award in
1975 in recognition of his 50 years
in medicine.
Dr. Nicholas M. Juhasz
Nicholas Miklos Juhasz, M.D., a
family practitioner in Neptune City,
died May 25, 1984, at Jersey Shore
Medical Center. Bom in Hungary in
1919, Dr. Juhasz obtained his medi-
cal degree at the United Peter Paz-
many University in Budapest, in
1945. He emigrated to the United
States in 1950, and established his
practice in Neptune City in 1959. Dr.
Juhasz was affiliated with Jersey
Shore Medical Center, Neptune, and
had been a member of the American
Medical Association and an As-
sociate Fellow of the American Col-
lege of Angiology.
Or. Michael L. LaPorta
At the untimely age of 57, Michael
Luigi LaPorta, M.D., died at Reggio
Calabria, Italy on May 19, 1984. Dr.
LaPorta was bom in Calimera- Lecce,
Italy and was graduated from the
University of Rome’s School of Medi-
cine in 1953. Emigrating to the
United States that same year, he
practiced his specialty, anesthesi-
ology, in the West Long Branch and
Sea Girt areas for the next 15 years.
In 1967, Dr. LaPorta did volunteer
work in Colombia, South America,
with Project HOPE; among his ser-
vices was teaching three native doc-
tors his specialty and lecturing to
medical students in Spanish. Dr.
LaPorta was board certified in
anesthesiology, a Fellow of the Inter-
national College of Surgeons, a Fel-
low of the American College of
Anesthesiologists, and a member of
the American Medical Association.
At the time of his death. Dr. LaPorta
was head of the anesthesiology de-
partment and intensive care unit at
Brindisi Regional Hospital in
southern Italy.
Dr. Norman V. Myers
Norman Van Sant Myers, M.D., a
member of our Bergen County com-
ponent, died on April 28, 1984. Bom
in Pleasantville in 1908, Dr. Myers
was graduated from Jefferson Medi-
cal College in 1933. He established
a practice in proctology in Engle-
wood, and was affiliated with
Englewood Hospital for many years.
Dr. Myers was president of the New
Jersey Proctologic Society in 1958,
and was a member of the American
Medical Association. During World
War II he served in the United States
Navy with a rank of lieutenant com-
mander. In 1983, Dr. Myers received
MSNJ's Golden Merit Award honor-
ing his 50 years as a physician.
Dr. John C. Voss
Congestive heart failure claimed
the life on May 17, 1984, of John
Carl Voss, M.D., a retired physician
of Riverton. A native of Reading,
Ohio, bom in 1908, Dr. Voss re-
ceived his medical degree at Temple
University School of Medicine in
1934. He was a practitioner of family
medicine, and, prior to his retire-
ment in 1976, had been affiliated
with Zurbrugg Memorial Hospital,
Riverside, Dr. Voss was a member of
the American Medical Association
and of our Burlington County com-
ponent.
Dr. Thomas J. White
A recipient of MSNJ’s Goldi
Merit Award in 1975, Thom.
Joseph White, M.D., died on May y
1984, in St. Vincent’s Hospital, Nr
York City. Bom in Jersey City, I
White received his medical degn
from Cornell University Medical G
lege in 1925, and until his refill
ment in 1981 had practiced as Hi
internist and cardiologist in f
native city for 56 years. Dr. Whil
was a professor of medicine at Setcl
Hall University and UMDNJ-N(I
Jersey Medical School, and chief
medicine at St. Francis Hospit s
Jersey City and St. Mary’s Hospit
Hoboken. Dr. White was a Fellow
the American College of Physiciai
and a Diplomate in internal met
cine/cardiovascular diseases. I
served for 20 years as chairman
the board of the Blue Shield Plan
New Jersey, had been president
the New Jersey Heart Associatio
and was a founder of the Hudsc
County Heart Association. Dr. Whi
was a past president of The Acaden
of Medicine of New Jersey, a memb
of the Board of Managers at Jers<
City Medical Center, and person
physician to former Mayor Frar
Hague. He was 87 years old.
Dr. Frances L. Willoughb
Frances Lois Willoughby, M.D., tf
first woman doctor to serve in tf
United States Navy, died on May 1. 1
1984, at Underwood Memorial Ho:
pital, Woodbuiy. Bom in 1905, i
Harrisburg, Pennsylvania, D
Willoughby received her medic
degree from the University of Arkai
sas School of Medicine in 1938. Sf
practiced psychiatry in Glassbor
until 1944 when she was inducte
into service by the United State
Navy with the rank of captain. Sh
served until 1964 when she ri
turned to practice in Glassboro. D
Willoughby was a member of oi
Gloucester County component, an
a member of the American Media!
Association. She was affiliated wit
Underwood Memorial Hospital. D
Willoughby was a Fellow of tb
American Psychiatric Associatior
and of the American Association fo
;
the Advancement of Science, as we
as being a Diplomate in psychiatr
and neurology. In 1981, Di
Willoughby received the Benjami
Rush Award, the nation’s most pres
tigious citation in psychiatry.
686
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
iUthor Information
Style
Sheet
fhe Journal is the
official organ of the
Medical Society of New
Jersey. The goals of The
Journal are educational
md informational. All
material published in The
Journal is copyrighted by
MSNJ.
INTENT
jrhe educational content of each
|ue appears as scientific articles,
sed on research, original concepts
ative to epidemiology of disease,
Id treatment methodology; case re-
rts based on unusual clinical ex-
riences: review articles; clinical
tes, succinct items on some
ipect or new observation or tech-
bue of a case experience; and
iecial articles, which include evalu-
ons, policy and position papers,
d reviews of nonscientific sub-
bts. Other topics include commen-
y (critical narration); medical his-
y: therapeutic drug information;
diatric briefs; nutrition update;
d an opinion column. Editorials
b prepared by the Editor and by
est contributors on timely and rel-
iant subjects; editorials are the re-
jonsibility of the author. The Doc-
's' Notebook section contains or-
(nizational, informational, and ad-
nistrative items from MSNJ and
>m the community. Letters to the
litor and book reviews are wel-
me and will be published as space
units. The principal aim in the
eparation of a contribution
ould be relevance to diagnosis and
?atment and to education of pa-
nts and professionals. Preference
111 be given to professional authors
>m New Jersey and to out-of-state
turers who submit a suitable
•L 81— NUMBER 8— AUGUST 1984
manuscript based on a presentation
made in New Jersey.
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687
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
CLASSIFIED ADVERTISEMENTS
iBSTETRICIAN/ GYNEOLOGIST —
oard certified, experienced with estab-
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> relocate practice to New Jersey
Camden or Burlington Counties),
iterested in partnership and/or call-
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ox No. 93. JMSNJ.
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?rsonable American-trained MDs. Send
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VTE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
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imbers, hyphenated words. Count name and address as five words, telephone number as one word, and “Write Box No. 000,
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)L. 81— NUMBER 8— AUGUST 1984
689
MIDDLESEX
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THE MOOLTEN LECTURES
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POSTGRADUATE INTERNAL
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Twenty-ninth Series
Sponsored by: Middlesex General-University Hospital, UMDNJ-Rutgers Medical School, Th
Academy of Medicine of New Jersey, The New Jersey State and Middlesex County Chapters
The American Academy of Family Physicians.
Meeting Place: Middlesex General-University Hospital— UMDNJ-Rugters Medical School, New Bruns
wick, New Jersey
Date: Wednesdays, 9:00 to 11:00 A.M. starting October 10, 1984 and ending May 22, 1985.
Program Chairman: Dr. Hadley Conn, Jr., Professor, UMDNJ-Rutgers Medical School
“The Moolten Lectures in Postgraduate Internal Medicine and Therapeutics,” given annually will begi-
their 29th year this coming October. The 1984-1985 series can fulfill 60 prescribed AAFP credits as we|
as 60 category I credits for the continuing education requirements of the Medical Society of New Jerse
and the Physicians Recognition Award of the American Medical Association. It also can fulfill 60 credit
to category 2D of the American Osteopathic Association.
As in previous years the program is designed to provide concise reviews of important advances in interns
medicine that are of practical interest to internists and family practitioners. All 30 sessions are presentee
by outstanding physicians from the faculties of large medical centers. Participants are given the op.
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The fee for the entire Course is $400. For residents $100. Discounts for early registration. Parking i:
•j available.
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690
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
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VOL. 81— NUMBER 9— SEPTEMBER 1984
691
September 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1766
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
President Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
Erst Vice President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr„ M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Councilors
Erst District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Efth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D Elia M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
Henry J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood)
Publication Committee
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosniek, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/ Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Alan J. Lippman, M.D. (Oncol)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr„ M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of New
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Printing
Co Whole number of issues 966. Member’s subscription (SlO) is included in Society dues. Rates for nonmembers,
$20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, Two
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and additional
entry office. Copyright 1984 by the Medical Society of New Jersey.
692
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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The Journal
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SEPTEMBER 19*
■■■■Medical History
70 1 The Lenape Contribution to New Jersey Medicine
Thomas P. Fitzpatrick, Teaneck
709 A Sketch of Medicine in New Jersey to 1825
Morris H. Saffron, M.D., Lawrenceville
7 1 8 MSNJ: America’s First and Oldest Medical Society
Geraldine Hutner, Lawrenceville
723 The History of Medical Journalism in New Jersey
Arthur Krosnick, M.D., Lawrenceville
73 1 Preliminary Report of Yellow Fever During the 18th Century
William J. Snape, M.D., and Edward L. Wolfe, Ph.D„ Haddonfield
737 The History of Medicine and Medical Care in New Brunswick
Norman Reitman, M.D., Highland Park
7 40 The Life and Times of Camden
Sam Alewitz, Ph,D„ Gloucester Township
On Display i
747 The Science and Art of Healing
Stuart Sammis and Eric Dummett Newark
■^■Medical Personalities
759 Samuel Alexander, M.D., and the Uniform Medical Practice Act
Stewart F. Alexander, M.D., Park Ridge
765 Frederick B. Kilmer: A Notable New Jersey Pharmacist
Roy A. Bowers, Ph.D„ New Brunswick
769 William Augustus Newell, M.D., and the Life Saving Service
Peter J. Guthom, M.D., Brielle
773 Women Physicians in New Jersey: The Early Era
Christine E. Haycock, M.D., Newark
779 A Medical Dynasty in New Jersey
Estelle Brodman, Ph,D„ Hightstown
Medical Specialties
The Academy of Medicine of New Jersey: A Brief History
Morris H. Saffron, M.D., Lawrenceville
Medical Education of New Jersey: The Development of UMDNJ
Stanley S. Bergen, Jr„ M.D., Newark
The First 40 Years of Osteopathic Medicine in New Jersey
Robert L. Thompson, EcLD., and Christine Chico, D.O., Piscataway
The History of the New Jersey Hospital Association
Linda Staab, Princeton
New Jersey State Nurses’ Association
Janet L. Fickeissen, R.N., Lanoka Harbor
Mi Bibliography i
807 New Jersey Medical Historiography: 1964-1984
David L. Cowen, MA„ LittD., Rossmoor
ftyg&u MSNJ Department
811 CME Calendar
On The Cover: The Journal is cel-
ebrating 300 years of medicine in
New Jersey. This issue highlights
the history of medical care in the
Garden State. Our cover is by
Frank Cecala
785
791
798
802
805
694
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'1
JJ5NJ Members . . .
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VOL. 81— NUMBER 9— SEPTEMBER 1984
695
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Start with 80 mg once daily. . . Dosage may be increased to
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Please see next page for further details and brief summary of
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80 120 160
mg mg mg '
The appearance of INDERAL LA capsules
is a registered trademark of Ayersf Laboratories
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
80
mg
120
mg
10
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL" LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and jpajnewhat variable INDERAL has
been shown to cause a small increase in serum potassiJBconcentration when used#! the
treatment of hypertensive patients. flf— _ JL_
In angina pectoris, propranolol generally reduces thpftvn redHAM^MBHl
any given' level of effort by blocking the catecholamine JHJBb increases in the h^p, rate,
systolic blood pressure, and the velocity and extent otfnyocardial pontractipa : /Propranolol
may increase oxygen requirements by increasing left ventricular lifter lengW>$S$ ;3$stolic
pressure and systolic election period The net physiologic effectof^%^<j^,^W^^tode
is usually advantageous and is manifested during exmr so bv delay'd onset pain land
increased work capacity MB
In dosages greater than required for beta blockade. INDERAL also exerts a quinidine-l|isf
or anesthetic-like membrane action which affects the cardiac action potential;' The signifi-
cance of the membrane action in the treatment of iSarfceffm^P^^^ jHlP
The mechanism of the antimigraine effect of propranolol has not been established Beta
adrenergic receptors have been demonstrated in ,ihe pint ves sefs df YHe brain
Beta receptor blockade can be useful in concHfens in wliich. because of pathologic or
functional changes, sympathetic activity is detrirr^»^m§^^^)i’pullthere are also
situations in which sympathetic stimulation is vital Forexample In patients wfrnseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking thejj
prior to major surgery is controversial. It should be noted, however, that the impaired abil||
u
’1
the heart to respond to reflex adrenergic stimuli may augment the risks of general anestKa
and surgical procedures ; >
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor ol t.L 1
receptor agonists and its effects can be reversed by administration of such agents,
dobutamine or isoproterenol. However, such patients may be subject to protracted see fi
hypotension Difficulty in starting and maintaining the heartbeat has also been reported \ ■*
blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent thejljjt
pearance of certain premonitory signs and symptoms (pulse rate and pressure change')
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be r,i ,.k
difficult to adjust the dosage of insulin. !’ "U
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroid , ,
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sympt j )j jj
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function t<
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have t
reported in which, after propranolol, the tachycardia was replaced by a severe bradyca
requiring a demand pacemaker In one case this resulted after an initial dose of 5
propranolol
PRECAUTIONS. General . Propranolol should be used with caution in patients with impa
hepatic or renal function. INDERAL is not indicated for the treatment of hyperten
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Pain
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal i
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dise,
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re
pine should be closely observed if INDERAL is administered The added catecholam
blocking action may produce an excessive reduction of resting sympathetic nervous acti
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthost
hypotension
Carcinogenesis. Mutagenesis. Impairment ot Fertility Long-term studies in animals h
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studie
.both rats an d rp^errijrloytHg.doses^ij^glSO mg/kg/day. there was no evidence of sigmfic
drug-induced, toxicity There wem no drug-related tumorigemc effects at any of the dost
LiYlevelS Reproducpe studies in animals not show any impairment of fertility that r
attributable io the drug.
fiffigAisjncy Preqnahcy CgUgiftry CJfJDERAL has been shown to be embryotoxic
animal stufies agdgses about 10 times greater than the maximum recommended human dc
^NsB^hJfPare njTOeqwSPInd weft-con* m loo studies in pregnant women INDERAL sho
be used during pregnancy only if the potential benefit justifies the potential risk to the fel
Nursing MotEMs INDERAL is excreted in human milk Caution should be exercised wl
ministered to a nursing woman
ctivgjpfes in children have not been established
ads&se effects have been mild and transient and hi
I
V;
rt failure, intensification of AV block; hy|
rpura; arterial insufficiency, usually of
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
lareiyt^sjuired^^withdrawai <
pi umjiovascular: bradycardi
pension; paresthesia ot hands.
TRaynaucrfype v-- - 3
Central Nervous System : tiQtjtfieadedness. mental depression manifested by msomr
lassitude, weakness. tatigudWversible mental depression progressing to catatonia, vis
disturbances, hallucinations; an acute reversible syndrome characterized by disorientation
time and place, short-term memory loss, emotional lability, slightly clouded sensorium, a
decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhi
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined withachi
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytoperi
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has be
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imp;
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous reactio
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practof
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride ir|
sustained-release capsule for administration once daily If patients are switched from INDER/1
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeul !
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute 1 1
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitration m; |
be necessary especially to maintain effectiveness at the end of the 24-hour dosing mterv,
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 n
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may t1
increased to 120 mg once daily or higher until adequate blood-pressure control is achieve;
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage of 6*;
mg may be required The time needed for full hypertensive response to a given dosage .1
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL L]
once daily, dosage should be gradually increased at three to seven day intervals until optimu
response is obtained. Although individual patients may respond at any dosage level, tt
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value ar
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few week
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDERAL Lj
once daily The usual effective dose range is 160-240 mg once daily The dosage may bj
increased gradually to achieve optimum migraine prophylaxis If a satisfactory response is ml
obtained within four to six weeks after reaching the maximum dose, INDERAL LA theraf'
should be discontinued It may be advisable to withdraw the drug gradually over a period ij
^HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group are to]
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratory.
Hcnallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N Y. 10017
698
VOL. 81— NUMBER 9— SEPTEMBER 1984
300 Years of Medicine in New Jersey
The Journal of the Medical Society of New Jersey with this special issue
is honoring the knowledge and sophistication of its medical community.
“One measure of a civilized community could well be the extent of its
acquired medical knowledge and sophistication.” So states eminent New
Jersey historian and author, David Cowen.
This issue of The Journal was conceived as a means of presenting to the
citizens of New Jersey, both physician and layman, a history of the “healing
art” in our state; for to understand where one is going, one must understand
where one has been. The history of medicine often is viewed as the history
of scientific misconceptions and quackery — that health professionals and
their work are isolated from the rest of society. This issue we hope will dispel
many of these erroneous myths as we present articles covering a broad
spectrum of the “healing art.” Articles reveal the contributions made to
society by physicians outside of medicine, physicians who were involved in
the political and military fight for independence, women who helped open
the doors to equal opportunity in medicine, and crusaders for the rights,
health, and safety of industrial workers and sailors.
In the realm of medical contributions, there are articles which discuss
the early acquisition of medical knowledge by the Lenape Indians, the
founding of our medical society (the oldest in the nation), the growth of
the various aspects of health care, and some of the leading medical associa-
tions and personalities. Of particular use to researchers is the extensive
bibliography of publications on the history of medicine in New Jersey.
The photographic section highlights the exhibits produced by the Middle-
sex County Cultural and Heritage Commission, the University of Medicine
and Dentistry of New Jersey-Rutgers Medical School, and the Middlesex
General/University Hospital, celebrating 300 years of medicine in New Jer-
sey.
“300 Years of Medicine in New Jersey” is cosponsored by The Journal
of the Medical Society of New Jersey and the Middlesex County Cultural
and Heritage Commission. Publication was aided by a grant from (•) the
New Jersey Committee for the Humanities. Financial support was received
from Sandoz, Inc., Merck, Sharpe & Dohme, Knoll Pharmaceutical Company,
and Johnson and Johnson to help defray the costs of this special issue.
Morris H. Saffron, M.D., Guest Editor
Archivist-Historiarv Medical Society oj New Jersey
and The Academy oj Medicine of New Jersey
Stuart Sammis, Project Director
Archivist University oj Medicine and Dentistry
Arthur Krosnick, M.D., Editor
The Journal, Medical Society oj New Jersey
Geraldine Hutner, Managing Editor
The Journal, Medical Society oj New Jersey
3L. 81— NUMBER 9— SEPTEMBER 1984
699
|p;
600 mg Tablets
Fpjohn
©1984 The Upjohn Company
The Upjohn Company • Kalamazoo, Michigan 49001 USA
j-4044 January
e Lenape Contribution
ro New Jersey Medicine
Thomas P. Fitzpatrick, teaneck*
The colonists and doctors of early New Jersey owe a debt to the
original inhabitants of the state , the Lenape . The medicine plants
and cures of the Lenape people left a legacy that can be found
in our medical folklore, and it can be said the Lenape were the
first medical practitioners and pharmacists in New Jersey.
The diversity of the Lenape
people* scattered throughout
New Jersey precludes stating a
harmacopoeia known and used by all the different
ands. The development of curative practices by indi-
iduals resulted in the application of a specific herb
>r different ailments, while the sacred aspects of some
lants and their potential power made many Amer-
idian herbalists reluctant to share their acquired
nowledge of specific plants with the colonists. As a
?sult of conflicts with the Europeans, the Lenape be-
ame distrustful and resentful of the settlers’ motives,
nd hesitant to aid them with their medical expertise.
The herbal remedies of the Europeans and the
merindian tribes they came into contact with altered
ae Lenape’s pharmacopoeia by close association or
itermarriage with members of these groups. As the
enape migrated westward, some new herbs in the new
oras were included in their medical repertoire. The
est source of information comes from the journals of
ae Swedish and Dutch colonists. Although some of
aeir leaders were interested in botany, and either de-
aribed the plants used by the Lenape, or sent some
f the plants to Europe for examination, many of the
^ttlers primarily were interested in acquiring land
nd furs, and not the medicinal knowledge and as-
aciative restorative practices of the local people.
The assertion that the colonists used many Lenape
ledicine plants can be supported from the scanty ref-
erences in the settlers’ journals of Europeans being
cured by Native American herbalists and by the early
inclusion of many plants unknown in Europe in the
recipe books kept by colonial housewives. These books
often included notations such as “squaw remedy,”
often giving detailed directions on how to dispense the
medicinals which paralleled Lenape usage.
Although the Europeans had a rich herbal folklore
of their own, their plant supply was limited at first by
the amount of dried material brought over on ships,
or the successful germination of herbs from seeds. If
their supply of medicine plants was cut off, they either
had to locate plants similar to the ones they were fa-
miliar with in their homelands, or use trial-and-error
or the “doctrine of signatures” to find an herbal cure
for an illness. The “doctrine of signatures,” which held
that the shape or color of particular plants pointed the
way to cures, was used by Europeans and Amerindians
alike. Either of these alternatives was likely to be un-
Thomas P. Fitzpatrick is an art teacher in the Teaneck Pub-
lic Schools and a research associate of the Archaelogieal Re-
search Laboratory at the Van Ripper-Hopper Museum in
Wayne.
+Lenape or Lenni-Lenape were the names used by several
closely related Amerindian tribes of the Algonquian branch of
the Algonquian-Wakashan linguistic stock, who lived in what
now is New Jersey, Delaware, Eastern Pennsylvania, and
Southeastern New York. They were called the Delaware In-
dians by the early European settlers because they lived in the
vicinity of the Delaware River.
fOL. 81— NUMBER 9— SEPTEMBER 1984
701
successful or produce death by poisoning. In the event
the plants were medically effective for a given com-
plaint, the specific plant part that would produce the
cure, the proper gathering season, the dosage, and
method of preparation, and the application would have
to be known to produce the desired result and avoid
overdosing.
The Lenape assisted the early settlers on a number
of occasions by giving them shelter, providing food,
teaching them how to hunt, and how to procure wild
foods and avoid poisonous ones. References also are
available on native “doctors” using their remedies to
cure the ailments of the early colonists. If the Euro-
peans could not make use of their own pharma-
copoeias, and if one of the handful of early doctors was
not available or did not have access to the necessary
medicinals, a Native American herbalist might be
prevailed upon as a last resort to tiy to cure the patient.
Bit by bit, some of the indigenous plants and rem-
edies found their way into the colonists’ homes, sup-
planting, or used in conjunction with, their own herb
lore, thereby providing an abundant source of medi-
cine that did not have to be dearly paid for at a distant
apothecary shop. Even after patent medicines readily
became available from European and domestic
sources, the Lenape remedies did not fall into disuse,
but existed side by side with European remedies, being
eventually included in the United States Pharma-
copoeia, the National Formulary, and the Dis-
pensatory of the United States.
EUROPEAN MEDICINE AND FOLK MEDICINE
Names of doctors were unusual on the passenger
lists of ships laden with emigrants from the several
European countries that anchored in New Jersey
waters in the 1600s. As settlements began to prosper,
a few doctors ventured to this wild land, but as the
towns grew, the colonists searched out new land for
farms, slowly extending their distance from the main
settlements. In the 1600s, the 20 practitioners who
were present in the colony were hardly able to be on
call to all of the colonists who needed them, even if they
were close enough to be reached or rich enough to
afford their fees. Even if a doctor were within reach,
the settlers often were reluctant to trust their treat-
ments, which often as not were unsuccessful in curing
their complaints.
In order to understand why the colonial doctors were
not highly regarded, and why the leading physician of
New York was listed among the “small citizens” in the
town’s census of 1657, it is necessaiy to understand
the state of medicine in Europe at that time. The 1650
edition of the London Pharmacopoeia not only listed
the moss growing in the exposed skulls of hanged
criminals as being used for medicine, but the raspings
of the skull itself. Another reference, the Schroedero-
Hojfmann Pharmacopoeia of 1687, listed a formula
for an electuary containing almost 50 ingredients, in-
cluding such exotic materials as emeralds, sapphires,
coral, pearls, and topaz. Even though the colonial doc-
tors did not have access to many of the above ma-
terials, they improvised concoctions of their own. For
example. Governor Winthrop’s 1656 recipe for curing
ulcers used crab eyes; John Winthrop, Jr.’s cure for the
Figure 1 — Yarrow, Achillea millefolium (left) and Indi;
poke, Veratrum viride (right).
ague (intermittent fever with chills) consisted of pu
ting the parings from a patient’s nails into a bag tit
around the neck of a live eel; Doctor Salmon’s linimei
for sciatica in his 1710 Family Dictionary used amor
other things, newly whelped puppies and earthworm
The disillusionment with the often unsuccessf
cures offered by the practitioners of the time was con
pounded by the ineptitude of the many unqualifie
people who presumed to practice medicine withoi
any formal training, the dearth of accepted medicina
necessary to treat the maladies, and the limite
number of apothecaries available to prepare the ingr
dients. Early attempts were made by the colony
leaders to regulate the preparation of drugs and tl
practice of medicine, such as the Duke of York’s a
tempt to monitor apothecaries in New Jersey with pei
alties for malpractice in 1664. But schools for tl
training of physicians were scarce even in Europe, ar
a method of regulating those who were practicing d:
not appear until New Jersey required the examinatic
and licensing of physicians in 1772 — the first provin<
to do so.
This discussion explains some of the factors th;
necessitated the settlers’ attempts to utilize the floi
that surrounded them, especially the housewife, wl
often was the one relied upon to cure her family;
medical problems. It should be remembered that tl
Europeans who came to New Jersey brought with the;
a rich folklore of plant remedies used by the
ancestors. They found, growing in their new lan
plants, such as yarrow (Achillea millefolium) ar
hoarhound (Marrubium vulgare), just as they had i
their homelands, and they continued to use ther
Other plants, such as Indian poke or false hellebo
( Veratrum viride), blue flag (Iris versicolor), Americaj
ginseng ( Panax quinquefolius), and American pei;
nyroyal (Hedeoma pulegioides), were similar to sp
cies they knew in Europe, such as the European fald
hellebore (Veratrum album), stinking iris (Ir
foetidissima) and Florentine iris (Iris germanica), A
atic ginseng (Panax schin-seng), and European pei
nyroyal (Mentha pulegium). Since the American ar
related foreign species have the same essential coi
stituents, the emigrants could use the herb <
rootstock in the same amount and in the same w;
702
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
s their forefathers had with predictable results (Fig-
ire 1).
UROPEAN CONTACTS WITH LENAPE
[ERBALISTS
In a number of colonial homes, the housewife kept
collection of remedies or recipes to be used for vari-
us illnesses in a commonplace book. This handy refer-
nce was used in conjunction with, or in place of,
ledical books, such as Salmon’s Herbal, first pub-
ished in England in 1676, or a Collection oj Receipts,
lublished in 1755 by Robert Eastbum of New Bruns-
wick. Along with the medieinals known to European
ledicine are references to “Indian’s squaw” cures, and
p plants unknown in Europe, which explain how to
ollect the specific part of the plant to be used, the
mount, and the manner of preparation and appli-
ation. This type of folk knowledge was not developed
i one person’s lifetime by trial-and-error, but was the
roduct of generations of experience,
j While numerous books made reference to Euro-
eans’ using the Native American’s medicinal herbs,
ae above example of the “Indian squaw” cure only
uggests that the settlers learned of remedies from the
enape, or, as they often are referred to, the Delaware
idians. The journals of the early Swedish colonists
long the Delaware River, and the notebooks of Dutch,
(wedish, English, and German men of science give us
irst-hand accounts of some of the Lenape medieinals,
nd of cures performed on Europeans.
When the Europeans first arrived in New Jersey, the
enape were not a cohesive or tribal unit. Native Ameri-
ans were members of different autonomous groups,
'ho did not represent the intentions or interests of all
ae Lenape people. Nevertheless, many of the Euro-
eans were treated cordially by these separate groups,
he Dutch settlement at Bergen, begun by Danish or
orwegian emigrants around 1618, was allowed to
rosper and friendly relations ensued; in 1649, the
wedes obtained land on the New Jersey side of the
•elaware River, established settlements, and were
warmly greeted by the inhabitants. During the fall of
677, the English settlers who landed in the Bur-
ngton area were ill prepared for the winter, so the
ative Americans gave them food and shelter to
u reive.
Although some early hostilities had occurred in East
ersey, the Lenape never again trusted the Dutch after
ae massacre of 80 Native Americans in Pavonia (Jer-
ey City) in 1643. As the English obtained more and
lore of their former hunting grounds, the Amerin-
ians retreated farther away from the colonial settle-
ments, continuing to barter, but becoming more dis-
rustful of the settlers’ motives. The Swedish were the
nly group who continued to maintain friendly rela-
ions with the Lenape. A number of the Swedes learned
he Lenape language, tried to convert them, and acted
s interpreters for the English Quakers.
Due to the secrecy with which many Native Ameri-
an herbalists treated most of their medicinal plants,
is fortunate that we are able to identify any of the
pecies utilized by them. Since the Lenape lived in
cattered groups without a central government, no
harmaeopoeia or medical society existed to ensure
that medicinal knowledge of herbs and curative prac-
tices would be available to all herbalists. Any special-
ized knowledge that an individual practitioner ac-
quired was considered as a sacred trust not to be
openly shared with the uninitiated due to the powerful
nature of many of the agents. Despite these conditions,
it appears that some plant remedies were known and
used by the average Native Americans in the same way
that we use aspirin and witch hazel. The plants that
we know were used in specialized cures, however,
either must have been observed by the early settlers
or shown to them by native herbalists.
Some of the plants used by the Lenape for medicine
can be found in accounts such as The Representation
oj New Netherlands 1650, by Adriaean van der Donck,
a Dutchman who was the patroon of present-day
Yonkers and who praised the Amerindians’ use of local
plants for various illnesses. Gabriel Thomas, an Eng-
lish Quaker with the first group of William Penn’s
emigrants, mentioned some of the herbs and roots
used by the Lenape, and the ailments they were used
for, around 1680 in his An Historical and Geographi-
cal Account oj Pensilvania and oj West-New Jersey.
In The Journal of Andreas Hesselius, 1711-1 724, the
Reverend Hesselius, Swedish pastor of Holy Trinity in
Wilmington, New Sweden, described instances of the
Native Americans sharing their medical knowledge
with the early settlers. He related how his son was
purged of parasitical worms by a woman herbalist, and
how his servant was cured of a severe case of poison
sumac by the use of a bark medicine.
The accounts of scientists and doctors also provide
valuable information on the medieinals of the Lenape
in New Jersey. Peter Kalm, a Swedish-Finnish natural-
ist, visited the former colony of New Sweden in 1750.
In his Travels in North America, 1748 to 1751, he gave
a detailed and scientific description of American natu-
ral phenomena Although most of the Native Ameri-
cans had moved from the areas he visited, he obtained
information about Native American herbal cures from
a number of the old Swedes who had been treated by
the Amerindians. Dr. Johann David Schopf, a Hessian
physician of the British Army who remained in Ameri-
ca after the American Revolution, gave a picture of the
medicines of that time in a narrative of his travels.
Partial to the drugs of the New World, he wrote the first
Materia Medica Americana in 1787, which included
many of the Native American medieinals.
When the Lenape began their westward migration,
the Moravian missionaries recorded their curative
practices and medicine plants. John Heckewelder,
whose observations are recorded in the History, Man-
ners, and Customs oj the Indian Nations Who Once
Inhabited Pennsylvania and the Neighboring States,
worked among the Delaware in Pennsylvania and Ohio
from 1762 to 1786. An associate of Heckewelder, David
Zeisberger, worked among the Delaware in Penn-
sylvania, Ohio, and Canada from 1767 to 1808. His
History oj the North American Indians provides re-
liable information on the flora of the regions, describ-
ing in detail many Native American medieinals.
Another missionary, George Henry Loskiel, collected
the Amerindians’ herb cures noted by other United
Brethren ministers from 1735 to 1787 in his History
of the Mission oj the United Brethren among the In-
/OL. 81— NUMBER 9— SEPTEMBER 1984
703
dians of North America in 1794.
In 1821 to 1822, General Lewis Cass, Governor of
Michigan Territory, collected information through gov-
ernment agents and others in contact with the Dela-
wares and Monsies by using a questionnaire entitled:
Inquiries, Respecting the History, Traditions,
Languages, Manners, Customs, Religions & c. of the
Indians, Living Within the United States. He engaged
Charles C. Throwbridge as his private secretary and
assistant, and the two of them prepared manuscripts
based on data supplied by Delaware informants in
Ohio and Canada Although the manuscripts do not
mention specific medicinals, they do show that some
of the curative practices noted in the Lenape's eastern
homeland remained essentially intact.
A comparison of the accounts of the early settlers,
scientists, and doctors in the New Jersey area with the
migration observations of the Moravian missionaries
and the inquiries of Cass and Throwbridge all tend to
indicate that much of the medicinal knowledge of the
Lenape recorded outside of New Jersey probably orig-
inated in the state. The enduring strength of oral tra-
dition in preserving the cumulative knowledge of the
past makes it necessaiy to consider seriously much of
the information provided by the 20th century Dela-
ware informants. Herbalists, such as Wi-tapanoxwe,
one of the last Delaware men from Dewey, Oklahoma,
to prescribe herb cures, passed on a wealth of tra-
ditional medicinal herbs and curative practices when
interviewed in 1930. Nora Thompson Dean, also from
Dewey, Oklahoma, now in her early 70s, is one of the
last Delaware traditionalists. She made up a list of
medicinals used in Oklahoma that is similar to Wi-
tapanoxwe’s. Even though more than 300 years of cul-
tural intermixing and changing flora undoubtedly
have altered the Lenape's pharmacopoeia, a study of
the information provided by these 20th century in-
formants gives us a glimpse of the materia medica that
once existed in New Jersey.
IMPACT OF SPECIFIC LENAPE MEDICINALS
The plants used by the Lenape and the early colo-
nists eventually became incorporated in the stand-
ard medical references of the United States.
Two medicinal plants known to have been used by
the Lenape living in the New Jersey area are wormseed
( Chenopodium ambrosioides) and lady slipper or moc-
casin flower (Cyprepedium ocuale). Wormseed, used
by herbalists as an effective agent against intestinal
worms, also was used by Swedish settlers in New Jer-
sey and Pennsylvania in 1750 to rid children of the
parasites. CA. Weslager has remarked that this pos-
sibly was the same plant that a woman herbalist used
to cure Reverend Hesselius's two-year-old son when he
was wasting away from worms between 1712 and
1723. Many doctors in the 1800s used wormseed oil
as an effective remedy against roundworms, and it
became listed officially in the United States Pharma-
copoeia from 1820 to 1947, and in the National For-
mulary from 1947 to 1960. The 1973 Dispensatory of
the United States reports that although the oil is one
of the most effective drugs against roundworm and
hookworm, it has been superseded by less toxic
anthelmintics.
Lady slipper was noted as a native medicinal by van
der Donck in the 1600s and by Kalm in the 170C
Kalm wrote that a decoction of the root was effectf
for women in labor, and doctors in the 1800s used
as a sedative to quiet spasms of voluntary muscles ar
hysterical attacks. The roots were official in the Unitt
States Pharmacopoeia from 1863 to 1916 as an an:
spasmodic and as a nerve medicine. Its usefulness 1:
in its lack of narcotic or side effects, but it now h;
been replaced by synthetic agents.
Another pair of plants, the tulip tree ( Liriodendn
tulipfera) and the butternut or white walnut ( Juglai
cinerea), are examples of medicinals not used e
clusively by herbalists, but known and employed by tl
average Lenape. The bark of these trees was utilizt
for medicine not only in New Jersey, but during tl
westward migration as well. Dr. Eric Stone states th
the Lenape used a decoction of the fruit and the nr
bark of the tulip tree as a febrifuge, and Kalm in 171
recorded the Swedish settlers' use of the root bark
treat fevers, and the crushed leaves applied to the for
head for headaches. Loskiel noted the migratir
Lenape’s use, between 1735 and 1787, of the fruit ar
root bark to treat ague. Long used in domestic mec
cine, the bark was official in the United States Phc
macopoeia from 1820 to 1888 for its tonic ar
diuretic properties, and the Dispensatory of the Un
ed States reports that the bark also was useful i
treating rheumatism and digestive problems.
The butternut had been used in American medicii
since before the Revolutionary War as a laxative, ar
Doctor Barton, an 18th century Philadelphia phye
cian, used butternut for its purgative, anodyne, ar
blistering properties. A home remedy for raising
blister, from the commonplace book of the Hankinsc
family of Reading, begun about 1787, gives directioi
on how to collect the bark, the amount to be used, i
preparation, and its application. Butternut bark pi!
were used in one of the cures prescribed by Pet
Smith in the late 1700s. Smith described both himsr
and his father, Hezekiah Smith, who lived in New Je
sey, as “Indian doctors,” since most of their remedii
were used by the Native Americans. Zeisberger ar
Loskeil noted that the 18th century Lenape on the
westward trek used the bark as a styptic on freb
wounds to relieve pain, prevent swelling, and accelera
healing. The inner root bark was official in the Unitt
States Pharmacopoeia from 1820 to 1905 for its la, <
ative and tonic effects (Figure 2).
Some plants, such as the bayberry (Myrica pen
sylvanica), skullcap (Scutellaria laterifolia), Amei1
can elm ( Ulmus americana), and slippery elm (Ulmi
julva) have been documented as being used not orj
in the New Jersey area by the Lenape, but also
Oklahoma, the western terminus of the migration f
a large number of the tribe. The use of the bayber;
for medicinal purposes was noted by Kalm in 1748
1750, when an old Swedish settler informed him th
the Native Americans showed him how to use the ro
for a toothache remedy. Doctor Barton, in 1803, r
corded the bayberry’s use as an astringent, f
nephritis, kidney stones, and gonorrhea, while the w;
from the berries was used to cure dysentery. The ba
was official in the United States Pharmacopoeia fro
1820 to 1936 for its astringent and tonic propertie
and in the National Formulary from 1936 to 1950. W
704
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
''lire 2 — Skullcap, Scutellaria laterifolia (left) and bayberiy,
rica pennsylvanica (right).
!
i
; anoxwe reported the root as having curative powers
( the female generative organs, as well as being used
i a blood purifier and for kidney trouble.
|)r. Lawrence Vandeveer of Somerset, one of the
cnders of the Medical Society of New Jersey, ex-
> imented with Native American medicinals and
gan using skullcap in 1772. Vandeveer used skull
lib successfully to treat hundreds of patients suffering
Ijm hydrophobia or rabies, earning skullcap the
| fix of “mad dog.” The proceedings of the Essex
Onty Medical Society in 1823 recorded that a
tmber of patients were saved by this remedy. The
led herb became official in the United States Phar-
ncopoeia in 1863, where it was listed until 1916 for
I sedative and antispasmodie properties. The Okla-
$na Delaware, according to Wi-tapanoxwe, used the
jtnt top as a laxative and a stomach stimulant.
The bark of the American elm and slippery elm has
e same medicinal properties, and was used by doc-
Is during the American Revolution to treat gunshot
i unds. Used for its demulcent and emollient
uperties, slippery elm bark was official in the United
:: ites Pharmacopoeia from 1820 to 1936 and in the
V tional Formulary from 1936 to 1960. Accounts of
bark being used by the Delaware in Oklahoma
ve been given by Wi-tapanoxwe, who used American
: i bark for coughs and colds, and Nora Thompson
! an, who claimed that the bark was effective in stop-
:ig coughs and relieving chills.
"or a few species, Lenape usage can be documented
: the way from New Jersey, through Pennsylvania,
iliio, and into Oklahoma. Sassafras (Sassafras
lip idum), flowering dogwood ( Cornus Jlorida), and
'rginia snakeroot (Aristolochis serpentaria ) are ex-
lples of medicine plants that have followed the long
gration. Sassafras had been noted as an Amerindian
ifedicinal in the New Jersey area by van der Donck in
50, and by Thomas in 1698, who recommended it
a cure for venereal disease. New Jersey’s colonists
ed the root in the 1700s. Kalm was told by Swedish
ittlers that the Native Americans used the plant for
bating sore eyes, and Loskiel recorded the berries
Jng used as medicine by the Lenape east of the Mis-
i ssippi River between 1735 and 1787. The root bark
i is official in the United States Pharmacopoeia from
120 and 1926, when its oil, safrole, was used for its
ijitiseptic and pain relieving properties. The 1955 Dis-
|
>L.
81— NUMBER 9— SEPTEMBER 1984
pensatory of the United States reports that a hot in-
fusion of the bark was once a popular remedy as a
sudorific for colds, and was recommended for disinfec-
tion of root canals in dentistry and for nasal catarrhs.
The plant also was popular in Great Britain, where a
remedy known as Godfrey’s cordial, made by mixing
sassafras and opium, was listed in the National Form-
ulary IV in 1722. Both Wi-tapanoxwe and Nora
Thompson Dean listed sassafras among the med-
icinals of the Oklahoma Delaware. They used the bark
in a tonic to thin the blood, and so reduce high blood
pressure.
The root bark of the flowering dogwood was con-
sidered effective in treating malaria by Swedish set-
tlers in the former colony of New Sweden in 1750. In
the second half of the 1700s, the Moravian mission-
aries Zeisberger, Heckewelder, and Loskiel, who all
worked among the Lenape during their westward mi-
gration, claimed that the natives boiled the inner bark
in water to make a tea used to reduce fevers. Although
it was official in many editions of the United States
Pharmacopoeia, it now is only considered as a mild
astringent. Wi-tapanoxwe, in 1930, reported that the
Oklahoma Delaware used the root to make a tonic.
Virginia snakeroot, like sassafras, was another
Native American medicinal sent to, and utilized in
Great Britain, where it was official in the London Phar-
macopoeia of 1650 as a remedy against the poisonous
effects of snake bite; van der Donck listed it as a med-
icinal in that same year in New Netherlands. It became
a popular colonial remedy in the 1700s in New Jersey,
while at the same time being used by the Lenape east
of the Mississippi, according to Loskiel, as a sudorific
and stomachic. Visiting royalty Prince Maximilian of
Wied was shown the plant while staying at the Dela-
ware Gap in 1832, and was told that the inhabitants
used it as a styptic on wounds. It was official in the
United States Pharmacopoeia from 1820 to 1942 and
the National Formulary from 1888 to 1955 for its
tonic and stimulant properties. The Oklahoma Dela-
ware, according to Wi-tapanoxwe, used the root for its
tonic qualities (Figure 3).
CONCLUSION
The plants described indicate the debt the colonists
and doctors of early New Jersey owed to the original
inhabitants of the state. The medicine plants of the
Figure 3 — Flowering dogwood, Cornus Jlorida (left) and
sassafras. Sassafras albidum (right).
705
Lenape served the Europeans as well as they had their
predecessors, and paved the way for further ex-
perimentation with indigenous species, many of which
eventually were incorporated into our materia medica.
Even though the Lenape have all but migrated from
the state, they have left a legacy of medicinal plants and
cures that today can be found not only in the few
natural plant substances still used in pharma-
ceuticals, but in the folklore of mixed groups, such as
the Sand Hill Indians and the Ramapo Mountain
People of New Jersey.
The Sand Hill Indians were composed of Lenape who
never had migrated and Cherokee families who had
come from North Carolina in the early 1800s. They
lived near Asbury Park in Monmouth County from
1877 until recent times, and several plants that a
Native American informant claimed were used for
herbal cures also have been reported as being used by
the Lenape in Oklahoma. The list of herb cures and
folk remedies used by the group of people of mixed
racial aneestery that live in Ringwood and neighboring
towns, as recorded by David Steven Cohen in The
Ramapo Mountain People, also contains plants used
by the Oklahoma Delaware.
The use of sassafras, Virginia snakeroot, slippery
elm, and flowering dogwood by these contemporary
people does not prove that the remedies are of Lenape
origin, but simply indicates the continued existence of
herb cures that have been assimilated into the diverse
cultures that populate the state. Even if it is impossible
to prove exactly which of all the native cures originated
with the Lenape, it safely can be said that the inhabi-
tants of the state, before the coming of the Europeans,
were the first medical practitioners and pharmacists
of New Jersey.
REFERENCES
1. Barber JW: Historical Collections of New Jersey: Past
and Present. Spartanburg, SC, Reprint Co., 1868.
2. Benson AB, Hedin N: Americans From Sweden. Phili:.
phia, PA J.B. Lippincott Co., 1950.
3. Brown AC: Early American Herb Recipes. Rutland
Charles E. Tuttle Co., 1966.
4. Cohen DS: The Ramapo Mountain People. New Br
wick, NJ, Rutgers University Press, 1974.
5. Cohen DS: The Folklore and Folklife of New Jeh
New Brunswick, NJ, Rutgers University Press, 1983.
6. Cowen DL. Medicine and Health in New Jersey: A
tory. Princeton, NJ, D. Van Nostrand Co., 1964.
7. Cowen DL: Medicine in Revolutionary New Jei
Trenton, NJ, New Jersey Historical Commission, 1975.
8. Heckewelder J: History, Manners, and Customs ojM
Indian Natioi-is Who Once Inhabited Pennyslvania and >
Neighboring States. Philadelphia, PA Historical Societll
Pennsylvania, 1876.
9. Kalm P: Peter Nairn's Travels in North America.
York, NY, Dover Publications, 1937.
10. La Wall CH: The Curious Lore of Drugs and Medtcj?
Garden City, NY, Garden City Publishing Co., 1927.
1 1 . Newcomb WW Jr: The Culture and Acculuration of t
Delaware Indians. Anthropological Papers. No. 10, Ain Arr
MI, Museum of Anthropology, University of Michigan, II
1 2. Stone E: Medicine Among the American Indians.
York. NY, Hafner Publishing Co., 1962.
13. Tantaquidgeon G: A Study oj Delaware Indian M
cine Practice and Folk Beliefs. Harrisburg, PA Histoi
Commission, 1942.
14. Thomas G: An historical and geographical aecoun
Pensilvania and of West-New Jersey (1689), in Myers AC (
Narratives of Early Pennsylvania, West-New Jersey i
Delaware, 1630-1 707. New York, NY, Barnes and Noble, It
15. van der Donek A: The Representation of New Netl
lands ( 1650), in Jameson JF (ed): Narratives of New Netl
land. New York, NY, Charles Scribner Sons, 1909.
16. Vogel VJ: American Indian Medicine. Norman, ;
University of Oklahoma Press, 1970.
17. Weiner, MA Earth Medicine — Earth Food, NewYi.
NY: Macmilliam Publishing Co., Collier Books, 1980.
18. Weiss HB: Life in Early New Jersey. Princeton, NJ
Van Nostrand Co., 1964.
19. Weslager CA Magic Medicines of the Indians. Son
set, NJ, Middle Atlantic Press, 1973.
20. Weslager CA The Delaware Indian Westward Mic *
tion. Wallingford, PA, Middle Atlantic Press, 1978.
21. Zeisberger D: History of North American Indians. ("
umbus, OH, State Archeological and Historical Society, It
706
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE1
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL4 (propranolol hydrochloride) Tablets
CLINICAL PHARMACOLOGY
The Beta-Blocker Heart Attack Trial (BHAT) was a National Heart, Lung and Blood Institute-
sponsored multicenter, randomized, double-blind placebo-controlled trial conducted in 31
U.S. centers (plus one in Canada) in 3,837 persons without history of severe congestive heart
failure or presence of recent heart failure; certain conduction defects, angina since infarction,
who had survived the acute phase of myocardial infarction Propranolol was administered at
either 60 or 80 mg t i d based on blood levels achieved during an initial trial of 40 mg t.i.d.
Therapy with INDERAL, begun 5-21 days following infarction, was shown to reduce overall
mortality up to 39 months, the longest period ot follow-up. This was primarily attributable to a
reduction in cardiovascular mortality. The protective effect of INDERAL was consistent
regardless of age, sex or site of infarction. Compared to placebo, total mortality was reduced
39% at 12 months and 26% over an average follow-up period of 25 months The Norwegian
Multicenter Trial in which propranolol was administered at 40 mg q I d gave overall results
which support the findings in the BHAT
Although the clinical trials used either t i d, or q i d. dosing, clinical, pharmacologic and
pharmacokinetic data provide a reasonable basis for concluding that b i d dosing with pro-
pranolol should be adequate in the treatment of post-infarction patients.
CLINICAL: In the BHAT, patients on INDERAL were prescribed either 180 mg/day (82% of
patients) or 240 mg/day (18% of patients). Patients were instructed to take the medication 3
times a day at mealtimes. This dosing schedule would result in an overnight dosing interval of
12 to 14 hours which is similar to the dosing interval for a b.i.d. regimen. In addition, blood
samples were drawn at various times and analyzed for propranolol. When the patients were
grouped into tertiles based on the blood levels observed and the mortality in the upper and
lower tertiles were compared, there was no evidence that blood levels affected mortality
PHARMACOLOGIC. Studies in normal volunteers have shown that a 90 mg b.i.d. regimen
maintains beta blockade at, or above, the minimum tor 60 mg t.i.d dosing for 24 hours even
though differences occurred at two time intervals At 10-12 hours after the first dose of the day,
t i d. dosing gave more beta blockade than b i d. dosing; at 20-24 hours the trend of the rela-
tionship was reversed These relationships were similar in direction to those observed for
plasma propranolol levels (see Pharmacokinetics).
PHARMACOKINETIC' A bioavailability study in normal volunteers showed that the blood
levels produced by 180 mg/day given b i d. are below those provided by the same daily dos-
age given t.i.d at 10-12 hours after the first dose of the day but above those of a t.i d regimen
at 20-24 hours However, the blood levels produced by b.i.d dosing were always equivalent
to or above the minimum for t.i.d, dosing throughout the 24 hours. In addition, the mean AUC
on the fourth day for the b.i.d. regimen was about 17% greater than for the t.i.d. regimen (1,194
vs. 1,024 ng/ml- hr).
CONTRAINDICATIONS
INDERAL is contraindicated in 1) cardiogenic shock, 2) sinus bradycardia and greater than
first degree block, 3) bronchial asthma, 4) congestive heart failure (see WARNINGS) unless
the failure is secondary to a tachyarrhythmia treatable with INDERAL
WARNINGS
CARDIAC FAILURE; Sympathetic stimulation may be a vital component supporting circula-
tory function in patients with congestive heart failure, and its inhibition by beta blockade may
precipitate more severe failure. Although beta blockers should be avoided in overt conges-
tive heart failure, if necessary they can be used with close follow-up in patients with a history
of failure who are well compensated and are receiving digitalis and diuretics. Beta-
adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks and the patient should be cau-
tioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) PATIENTS WITH
BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA BLOCKERS.
INDERAL (propranolol hydrochloride) should be administered with caution since it rmil
bronchodilation produced by endogenous and exogenous catecholamine stimulation
receptors
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking ther|
prior to ma|or surgery is controversial. It should be noted, however, that the impaired r|
the heart to respond to reflex adrenergic stimuli may augment the risks of general ane
and surgical procedures.
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agoni:
its effects can be reversed by administration of such agents, e g., dobutamine or isop
terenol However, such patients may be sub|ect to protracted severe hypotension. Dih
starting and maintaining the heartbeat has also been reported with beta blockers.
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent the app
ance of certain premonitory signs and symptoms (pulse rate and pressure changes) <
hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be more i
to adjust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidism,
fore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoi
hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have t
reported in which, after propranolol, the tachycardia was replaced by a severe bradyi
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 mg
propranolol
PRECAUTIONS
General: Propranolol should be used with caution in patients with impaired hepatic or
function. INDERAL is not indicated for the treatment of hypertensive emergencies.
Beta-adrenoreceptor blockade can cause reduction of intraocular pressure. Patien
should be told that INDERAL may interfere with the glaucoma screening test. Withdrar
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart di:
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered. The added catecholami
blocking action may produce an excessive reduction of resting sympathetic nervous ;
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, oroi
static hypotension.
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies In animals
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stuc
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of :
cant drug-induced toxicity There were no drug-related tumorigenic effects at any of th
age levels. Reproductive studies in animals did not show any impairment of fertility the
attributable to the drug.
Pregnancy Pregnancy Category C INDERAL has been shown to be embryotoxic in
studies at doses about 10 times greater than the maximum recommended human dosi
There are no adequate and well-controlled studies in pregnant women. INDERAL st
be used during pregnancy only if th.e potential benefit justifies the potential risk to the I
Nursing Mothers INDERAL is excreted in human milk Caution should be exercised
INDERAL is administered to a nursing woman.
Pediatric Use. Safety and effectiveness in children have not been established.
ADVERSE REACTIONS
Most adverse effects have been mild and transient and have rarely required the withdi
therapy
Cardiovascular bradycardia; congestive heart failure; intensification of AV block; h'
sion; paresthesia of hands; thrombocytopenic purpura, arterial insufficiency usually oi
Raynaud type
Central Nervous System: Lightheadedness; mental depression manifested by inson
lassitude, weakness, fatigue, reversible mental depression progressing to catatonia; v
disturbances; hallucinations; an acute reversible syndrome characterized by disorieni
for time and place, short-term memory loss, emotional lability, slightly clouded sensorii
and decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrh-
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic : pharyngitis and agranulocytosis, erythematous rash, fever combined with ,
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Flematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has been
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imp
fence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reacti.
involving the skin, serous membranes and conjunctivae reported for a beta blocker (pi
lot) have not been associated with propranolol.
‘The appearance of INDERAL tablets is a registered trademark of Ayerst Laboratorie
8965/28
AYERST LABORATORIES
New York, N Y. 10017
Sketch of Medicine in
Jew Jersey to 1825
Morris H. Saffron, m.d., lawrenceville*
New Jersey has contributed greatly to the medical history of this
country . A brief sketch of the contributions by New Jerseyans
from 1664 to 1825 is presented.
When the English seized New
Netherlands in 1664, the terri-
tory now known as New Jersey
i [ready had been very sparsely settled by Swedes in the
titelaware Valley, by Dutch on the Hudson, and by Eng-
; sh on Newark Bay. Almost immediately, James, Duke
ijfYork (later James II) conveyed proprietorship of the
rovince to his friends. Lord John Berkeley and Sir
leorge Carteret; the subsequent division of the region
hto Calvinist East Jersey and Quaker-dominated West
ersey was to produce lasting effects on the political,
conomic, and cultural development of the two areas.
.Yen when the united province eventually attained its
wn royal governor (1738), the legislature, catering to
nutual mistrust and public bickering, agreed to meet
n alternate years at Amboy and Burlington.
MEDICAL LEGISLATION
Medical legislation in the province dates back to the
)uke of York Law (1665) intended “to restrain the
)resumptuous from expressing power contrary to the
ipproved rules, without the advice of those studied in
he art or the consent of the patient.” Although
-ouched in stem language, this law had practically no
effect on the charlatans who insisted on entering into
he practice of medicine at their own pleasure.
One authority claims that between 1680 and 1690
nembers of the medical profession held legal title to
me-quarter of the land in the present state of New
Jersey; certainly from 1692 to 1697, medically trained
Andrew Hamilton was entrusted with the governor-
ship of the entire province, during which time he es-
tablished the first successful postal system in America
In respect to medical control, however, it should be
noted that as early as March 1705, Governor Richard
Ingoldsby issued the following license at Burlington:
‘To Richard Smith, gentleman. Greeting. Being well
informed of your knowledge, skill, and judgment in the
practice of chirurgeiy and physic, I do hereby license
and authorize you to practice the said science of
chirurgery and physic within this her Majesty's prov-
ince of New Jersey.”
In May 1705, the Governor issued a similar license
to Nathaniel Wade and it was this benevolent character
who distilled medicines for gratuitous use among the
poor immigrants pouring into West Jersey.
CONDITIONS IN NEW JERSEY
Early settlers were uniform in their praise of the
beauty of the province, comparing favorably the
temperate climate of New Jersey with the bitter cold
winters of New England and the sulphurous summer
heat of Virginia Indeed, in spite of two early, devastat-
ing epidemics of smallpox or measles, recorded as early
as 1638 and 1641 in West Jersey, Charles Gordon of
Woodridge wrote discouragingly to his well-trained
physician brother in Scotland (1685): “If you desire to
*Dr. Saffron, Archivist-Historian of the Medical Society of New
Jersey, is Guest Editor of this issue.
VOL. 81— NUMBER 9— SEPTEMBER 1984
709
come hither yourself, you may come as a planter, or
a merchant, or as a doctor of medicine. I cannot advise
you as I can hear of no diseases to cure, but some agues
and cutted fingers, but there is no want of empiricks
for these already. I confess that you could do more than
any yet in America being versed in chirurgeiy and
pharmacie, for here are abundances of herbs, shrubs,
and trees, and no doubt ones for making drugs, but
there is little imployment in this way.”
By the year 1 700, the population of the province did
not exceed 20,000. One estimate places the number of
practitioners at this period at 20. In several counties,
Camden, for example, not a single trained physician
was to be found.
The instruction of medicine
in New Jersey was handed
down from generation to
generation.
As time went on, the early euphoria about the un-
usual healthfulness seemed to disappear as Europeans
brought with them not only smallpox, but measles and
venereal disease, while the swamps and stagnant
waters of Jersey spawned epidemics of malaria (ague)
and yellow fever. In 1714, measles again assumed
alarming proportions in Salem, and one observer wrote
“We had a sickly time this year. I buried more than in
ten years before.” Smallpox was prevalent in both Jer-
seys in 1716 and was so severe in Burlington that the
Assembly transferred its work to distant Crosswick.
Fifteen years later, yellow fever imported from Philadel-
phia caused the cancellation of the annual Burlington
Fair. The procedure of inoculation, introduced into
this country in 1721 by Zabdiel Boylston of Boston,
was supported strongly by the Reverend Cotton
Mather and this encouraged its ready acceptance by
the theologian-physicians who made up the bulk of
practitioners of East Jersey. As early as 1732, we learn
that “smallpox spreads very much in New Jersey at
Amboy, New Brunswick, and there away. Many have
been inoculated and not one of them has died, but have
had the distemper very easy.”
However, the most malignant and frightening
epidemic of all began in a small New Hampshire village
in 1735 and spread rapidly through New England to
reach New Jersey later in the same year. Called the
“throat distemper” it first was described by the Rever-
end Jonathan Dickinson of Elizabethtown who prac-
ticed medicine for almost three decades and whose
circuit extended to the Orange Mountain area; “The
long continuance and universal spread of this dis-
temper among us has given me abundant opportunity
to be acquainted with it in all its forms. The first
assault was in a family about ten miles from here
which proved fatal to eight of the ten children in about
a fortnight. Being called to visit the distressed family,
I found upon my arrival one of the children newly dead,
which gave me the advantage of a dissection and there-
by a better acquaintance with the disease than I other-
wise could have had.” The description which follows
clearly identifies diphtheria as the culprit, almost
century before the Frenchman Bretonneau finally gav
the entity its present name. Even Dickinson’s suj
gested treatment seems rational for the period: “Tal
some honey and the sharpest vinegar, with alum di;
solved therein, and let the patient often gargle it i
their throats; or if they be children, then take a feathc
and dip it into said liqueur and so wash their throats
NEW JERSEY PHYSICIANS
Dickinson also is famous as the founder and fir;
president of the College of New Jersey (Princeton) i
1747. Tragically, he contracted a virulent form (
smallpox following inoculation from which he sui
cumbed. Dickinson was representative of the ministei
physician, many of whom found it necessaiy to pra(
tice medicine in order to support their families. Th
most learned member of the community, the ministe
served not only as spiritual head, but also as healer c
the body. Having familiarized himself with the con
tents of such standard medical texts as Sydenharr
Culpepper, and Salmon, the minister-physician wa
well able to play this double role until long after th
mid-century when he gradually was superseded by ful
time practitioners. To anticipate, we may note that c
the 17 doctors who met in 1766 to organize the Medi
cal Society of New Jersey, no fewer than 6 were mei
of the cloth and the group unanimously elected as firs
president. Reverend Robert McKean of Amboy.
In Quaker-dominated West Jersey, physicians in
eluded several well-trained men of education an(
means, frequently of Scottish or Welsh origin. Beinj
business-oriented, they often supplemented their pro
fessional revenues by turning to agriculture, merchan
dising, and real estate ventures. Such a man was th<
learned Doctor Thomas Cadwallader, a resident o
Philadelphia who owned considerable property in the
Trenton area, and he became the first burgess of the
borough in 1746. Upon his retirement in 1750, he
donated 500 pounds for the establishment of a public
library in the town. His famous essay on the “Dr}
Gripes” or lead poisoning in the West Indies, dated ai
Trenton, March 25, 1745, shows his intimate connec
tion with our state.
A notable foreign observer of the period was the
Swedish physician, Peter Kalm, who spent 1747 anc
1748 studying the health of his countrymen settled in
the region of Penn’s Neck and Swedesboro. He noted
an epidemic form of “pleurisy” (pneumonia) which
decimated the older population. He attributed the early
loss of teeth among the Europeans to the excessive use
of tea; and observed the presence of a severe bloody flux
or dysentery endemic, and often fatal, among the
young people who also suffered from a rapid form of
consumption. Kalm mentioned the presence of a town
physician in the various communities who was paid
to take care of the elderly and indigent.
Other outbreaks of the period listed by John Duffy
included: Oyster Bay measles, 1730; Burlington flux,
1734; malaria when one missionary was “baited to
death with Muscatoes and Goluppers which did not
let him rest night and day,” 1738; Burlington yellow
fever, 1744; Perth Amboy smallpox, 1746; Eliza-
bethtown influenza, 1748; Perth Amboy smallpox,
1756; and influenza and typhoid, 1760s.
710
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
] EDICAL CARE
n the more isolated areas of the province, “kitehen-
jiysick” virtually was a necessity because of the infre-
cency of qualified practitioners. It was in these lo-
tions that the women of the community brewed their
Irbal concoctions or “Indian squaw cures” and took
ere of the assorted ailments.
n New Jersey, community instruction in medicine
jnost was obtained exclusively through the system of
cprenticeship, by which an intelligent youth, with
jme preliminary education and aptitude, would bind
Imself for a period ranging from four to seven years
t an older physician. Aside from learning to bleed and
('p, he was taught to prepare and dispense drugs, to
st bones and dislocations, to treat bums and arrow
; d gunshot wounds, to reduce hernias, and probably
I inoculate against smallpox. He also might encounter
J al cases of toadstool poisoning, rattlesnake bites,
; d rabies, or read about them in lurid accounts in
te weekly press. In many instances intimacy of the
; prentice with the physician’s family led to marriage
’ th one of the preceptor’s daughters, and subsequent
jirtnership. At any rate, on departure he usually was
Resented with “a new set of surgeon’s pocket instru-
lents” and several books.
With instruction in medicine being handed down
Ibm generation to generation it is not surprising that
’amilies” of doctors persisted in New Jersey through-
|it this early period. Prominent among these groups
[ere the Blachlys, the Budds, the Elmers, and the
ersons, each producing six or more physicians over
e years.
With the opening of Princeton College (1747) and
peens College (1766), standards for entering on a
'edical apprenticeship were raised considerably, and
knowledge of Latin and even Greek later was ex-
acted of the applicant. Although neither of these
istitutions gave medical courses, their presence on
irsey soil raised the general level of education and
imulated an interest in science on the part of their
'aduates inducing many to enter the medical pro-
ssion. Princeton and Queens had the right to confer
le medical degree by virtue of their royal charter.
The French and Indian War (1755 to 1763) brought
f) New Jersey an opportunity for advances in surgery,
lthough no fighting took place in the province itself,
lore than 1,000 Jersey Blues fought in the northern
ampaign from 1758. The construction of stone army
arracks in Burlington, New Brunswick, Amboy, Tren-
>n, and Elizabethtown brought well-trained English
urgeons who were willing to discuss medical matters
Hth civilian physicians or to impart their knowledge
p their surgical mates. As early as 1752, one surgeon,
I’homas Wood, advertised at New Brunswick the first
ourse of “osteology and myology” to be held on Jersey
oil, but it seems doubtful whether the lectures ever
/ere given. Surgery benefited as a result of this war
xperience. Operations now included fistula in ano,
nd especially “cutting for the stone,” since calculosis
/as prevalent among settlers of English ancestry. One
elebrated lithotomy was performed in Newark before
i select audience by the famous New York military
urgeon, John Jones, as early as 1767. The usual
harge for this procedure was five pounds.
Among the many Americans who profited by contact
with the British surgeons was another celebrated in-
oculator, John Cochran, a native of Pennsylvania, who
married the sister of General Philip Schuyler of Albany
and settled in New Brunswick after the war (1793).
During the French and Indian War, smallpox again
had become epidemic among the troops who brought
the disease home with them. Cumberland county suf-
fered greatly, and one observer wrote: “The fatal and
not to be forgotten year 1759 when the Lord sent his
destroying angel to pass through this place and re-
move many of our friends into eternity in a short space
of time.” Fortunately, inoculation, which had
languished as a result of unfavorable results, ex-
perienced a revival due to improved methods of prepar-
ing the patient. Bodo Otto, recently arrived from Ger-
many and settled in the Cohansey district of West
Jersey, was familiar with smallpox inoculation and
helped to control the epidemic in that region.
The most famous inoculator in the province was
William Barnet of Elizabethtown whose improved tech-
nique of preparing the patient was said to have saved
thousands. Benjamin Rush recalls that Barnet was
invited to Philadelphia in 1759 to demonstrate his
method and five years later he was called to Boston to
open the first inoculation hospital in the countiy at
Shirley Point.
Cochran, missing the stimulus of association with
fellow surgeons, became a leading spirit in the found-
ing of the Medical Society of New Jersey which held
its organization meeting at New Brunswick on July 23,
1766.
The first important transaction of the Society was
the establishment of a uniform fee schedule, but this
met with apprehension on the part of the public and
was subsequently modified. Of more lasting influence
was the passage by the legislature (1772) of “An Act
To Regulate the Practice of Physic and Surgery within
the Colony of New Jersey.” Designed to eliminate the
quacks who flourished like the locusts in Egypt,” this
pioneer effort soon set the pattern adopted by Massa-
chusetts and other colonies.
In the same decade, the first American medical
schools opened in nearby Philadelphia (1765) and New
York (1767), thus providing greater access to formal
medical education for New Jersey men. Jonathan
Elmer of Bridgeton and John Lawrence of Monmouth
county were among the members of the first gradu-
ating class of the Philadelphia school, whose
professors included such outstanding teachers as
John Morgan, William Shippen, and Benjamin
Rush — all European trained men who exerted wide
influence on their Jersey students. Of the 70 promi-
nent physicians mentioned by Wickes who practiced
in New Jersey during the latter half of the century, 44
were college graduates, 27 from Princeton but only 6
of these held medical degrees from foreign medical
schools.
A desirable influx of well-trained physicians of
French Protestant extraction came to New Jersey dur-
ing the period under discussion. Exiled from their
homeland by the Edict of Nantes, these descendants
of Huguenots included Daniel DeBenneville of
Moorestown, Nicholas Belleville of Trenton, John
Broguard of Burlington, Peter LeComte of Freehold,
71 1
43L. 81— NUMBER 9— SEPTEMBER 1984
and John A. de Normandie of Burlington. Born in the
latter town and closely related to the de Normandies
was John Bard, who with his son Samuel, was to be-
come influential in New York medical affairs. Bard per-
formed the first dissection in this country for teaching
purposes (1750) and his son helped to found the medi-
cal school of Kings College ( 1 767) and New York Hospi-
tal (1771). During the Revolution, the loyalist Samuel
returned briefly to Burlington where he worked in a
vain effort to manufacture salt from sea water.
THE MILITARY AND MEDICINE
The decade following the foundation of the Medical
Society of New Jersey was one of great political agita-
tion as the public (and families) split on the subject
of separation from the mother country. There was no
political unanimity among the physicians and several
of the more prominent and wealthy men decided to
remain loyal to the Crown: Absolom Bainbridge of
Princeton, David Bancroft of Burlington, John Boggs
of Shrewsbury, William Bryant of Trenton, the Rever-
end Isaac Brown and his son Samuel of Newark, Wil-
liam Chandler of Elizabethtown, Aaron Forman of
Hunterdon County, John Hammell and Charles A.
Howard of New Brunswick, Uzal Johnson of Newark,
John Laurence of Perth Amboy, John A. de Normandie
of Trenton, and the Reverend Jonathan Odell of Bur-
lington. On the other hand, over 70 Jersey physicians
who were of an age to fight, left their practices to
receive commissions either in the state militia or in
the Continental Army. Early in the Revolutionaiy War
(1775) smallpox became epidemic among the troops
and civilians of the Boston area, and Washington, who
at first feared inoculation as a general measure, finally
was persuaded by Director John Morgan to adopt the
measure enthusiastically.
On July 15, 1776, the famed Philadelphia anatomist
William Shippen, Jr., who previously had refused the
position of Director-General of the Medical Service,
offered to him by General Washington, was appointed
Chief Physician to the Jersey Flying (Field) Hospital at
Amboy, under the leadership of General Hugh Mercer,
himself a well-trained physician. Shortages of supplies
becoming immediately apparent, Shippen had the fol-
lowing advertisement inserted in a Philadelphia paper
"The good people of this city and province and of the
province of New Jersey are earnestly desired to send
all the old sheets and other old linen they can possibly
spare to Dr. Shippen, Jr., for the New Jersey Hospital.
None will refuse complying with this request when
they consider that the lint and bandages made of the
linen may be used in dressing and caring for the
wounds of their own fathers, husbands, or sons.”
Shippen’s originally optimistic tone faded by the fall
of 1 776 as a “putrid fever” began to attack men of the
Flying Camp. Furthermore, the growing struggle for
authority and the lack of cooperation between Shippen
who had been granted full authority in New Jersey and
Morgan who was confined to the west bank of the
Hudson undoubtedly greatly increased the suffering of
the sick in our state during this trying period.
New Jersey first felt the full impact of the war in mid-
September 1776, when the Continental troops de-
feated by the British at the battle of Long Island were
forced to evacuate New York City. Washington ordered
John Morgan, Surgeon-General, to transport aboi
1 ,000 sick and wounded over to the Jersey side of tl
Hudson, a heroic task which, despite “dreadful coi
fusion and disorder” Morgan accomplished with tl
aid of William Burnet, the leading surgeon of Newar
The latter, overriding the fears of infection of the loc
inhabitants, helped Morgan establish a general hosp
tal, using the two local churches, the court house, ar
the Academy; in October a second 300-bed facility w;
established at Hackensack.
As the battered troops of the American Army fk
south towards Trenton, other sick and wounded we
placed in Amboy, Elizabeth, and New Brunswick. In tl
latter town, Washington was joined by John Cochra
the zealous Whig, whose house became the target fc
British wrath. Cochran soon became a member I
Washington’s official “family” and later, in Janua
1781, succeeded Shippen as Director-General of tl
Hospital. In late December, Trenton saw the tic
change, but the death of General Mercer a few weel
later, from an infected bayonet wound received at tl
battle of Princeton, cast a pall on the troops and med
cal corps alike.
On January 9, 1777, John Morgan was summari
dismissed from the Army, to be superseded by h
arch-rival William Shippen, Jr., in April as Surgeoi
General. At this time many of the sick and wounde
in Jersey hospitals were transported to Pennsylvani
however. New Jersey was to remain the “cockpit of tl
Revolution,” with one-third of all the fighting takir
place on her soil.
At Morristown, where the army spent the winter i
1777, the small community was infected wit
smallpox, introduced by the troops. Inoculation bi
came the order of the day, and John Cochran supe
vised the procedure at the Jockey Hollow Huts with j
very low mortality rate of about 3 in 400 patient1
Civilians were treated by Reverend Green in the tu
churches of the town, while a smallpox hospital we
established at Hanover for soldiers who had contracte
the disease in the “natural way.” Another was estal
lished at Trenton Barracks which remained under th
supervision of the experienced Bodo Otto, who w£j
joined by his son, John Augustus, from July ii
Christmas of 1 777, when the two men left for Valle
Forge.
The problem of an adequate nursing staff was I
plague the Continental Army for the duration of tf
war. On June 17, 1777, General Washington at Middll
brook ordered that a “proportionate number of wome
to the sick of each regiment shall be sent to the hosp
tals at Mendham and Black Fdver to attend to the sicj
as nurses.” In November and December 1777, after th
defeats at Brandywine and Germantown, and the los
of Philadelphia, 400 sick and wounded were crowde
into the small town of Princeton where the hospit;,
was established at Nassau Hall, a structure whic
could accommodate at best only 150 men. A devasta
ing putrid infection (typhus) soon developed whic
carried off scores of injured who had come to the ho:
pital solely for treatment of wounds. Death came to n
less than six surgeons at this charnel house an
James Tilton, who barely escaped with his life, has le
us a vivid description of the morbid scene. Fortunate!
other Jersey hospitals at Bordentown, Trenton, an
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
712
lirlington seem to have escaped this infection.
On June 28. 1778, the Americans, marching from
Hley Forge, tried unsuccessfully to stop the British
no were retreating from Philadelphia to New York. At
le batde of Monmouth, many were prostrated by the
i tense heat, the sick and wounded being cared for in
le Freehold Courthouse and several local churches.
( hers were moved to the New Brunswick barracks
; d to Morristown where the hospital was reopened.
Iter in 1778, the bulk of Washington’s army en-
cmped for the winter at Middlebrook, from which the
i:V sick and wounded were sent to hospitals at Bound
l ook and New Brunswick. This winter proved to be
uusually mild and healthful, and it was at Middle-
look that Washington ordered a series of lectures to
1 supervised by Dr. William Brown of Virginia Phy-
« ian-General of the Middle Department— this may
oil have been the first such course ever to be given
j New Jersey.
The following winter (1779 to 1780) the Army again
rose Morristown, but during this winter the climatic
(jnditions proved to be appalling, exceeding in severity
te harsh period at Valley Forge. The men were forced
i sleep in tents until February when huts finally could
1 erected. Despite the frightful weather, mortality was
liv; the number of fatalities at the small general hospi-
lils at Basking Ridge and Pluckemin from December
'79 to June 1780 amounting to only 86 of a force of
f ,500 men. It was at Basking Ridge that surgeon
ijimes Tilton had the opportunity to construct a novel
ledical hut. Windowless, with an earthen floor, and a
intral fireplace whose smoke circulated throughout
1 e hut before leaving through an aperture in the roof,
ie construction was credited with cutting down on
ifections and mortality. The huts at Jockey Hollow,
rich had been used by the Pennsylvania line until
«iily 1780, then were reopened as a general hospital.
Ick men were sent there from the Paramus encamp-
ment, and the huts were still in use as late as June
j;81.
4E POSTREVOLUTIONARY YEARS
With the war almost over, the Medical Society of New
crsey immediately resumed its activities in November
781, and by 1790 was incorporated formally by the
legislature for a period of 25 years.
Topics which engrossed the minds of the better
jained physicians of the day can be found in the
jinual addresses given by the presidents of MSNJ
Dm 1767 to 1795: use of lancet in pleurisy (em-
j/ema); intermittent fevers; putrefaction: inoculation;
operties of blood; nephritis; cachexia; changes of
|ood in disease; mechanisms of the human
bdy — fluids and solids; health and disease; nutrition;
ature and uses of animal secretions; natural
lenomenon of sleep; chemical principles of bodies;
fferent properties of air contained in the atmosphere;
-itridity; cyanche; causes of vital heat and animal
notions; beneficial effects of bathing; dropsy; and
-ilmonary consumption.
At this period Paul Micheau, a well-trained phy-
ician, fostered a schismatic group known as the East-
n District Medical Society, in opposition to the Medi-
il Society. Apparently with the idea of founding a
edical school, Micheau also gave a course of lectures
on the practice of medicine, from May 10 to July 25,
1790, for which he charged the sum of five pounds.
Drawing on the heavy concentration of physicians in
the Newark-Elizabethtown area, he made it impossible
for the parent society to assemble a quorum in West
Jersey where only one-sixth of the Society’s physicians
resided. As a result, the State Society remained quies-
cent from 1795 until 1807 when meetings were re-
sumed. Ely 1800, ten New Jersey physicians had been
granted the medical degree by schools in Philadelphia
and New York. During this very period Jenner’s vacci-
nation was introduced into Boston by Benjamin
Waterhouse. It was Lewis Condict of Morristown, a
friend of the latter, who first brought the method to
New Jersey in 1802. It was adopted by Cyrus Pierson
of Essex County and James H. Stokes of Moorestown,
with all three men testing the effect of vaccination on
their own offspring by later exposing them successfully
to smallpox. John Bowne of Ringoes, who at one time
had 300 young persons under inoculation, also put
vaccination to the severest tests in order to prove its
efficacy.
Following the resumption of Society meetings in
1807, topics discussed included inflammatoiy peri-
pneumonia, puerperal fever, tetanus, pneumonia ty-
phoides, psoas abscess, fungus hematoides, in-
tussusception, digitalis, calomel, alkalies in pulmonaiy
consumption, and chorea
Women, who had been taught the rudiments of
medical care, continued to dominate the practice of
obstetrics; one early example being “Aunt” Peggy
Warner of Warren County who defied rain and snow
during the Revolution in her travel on horseback along
unlit country roads. The man-midwife finally made his
way to New Jersey, and by 1 775, a retired army surgeon
in Rahway was advertising that he was skilled in the
art of midwifery after studying at the famous Lying-
In Hospital. James Stratton of Swedesboro also was
familiar with the use of Smellie’s forceps. The charge
for natural delivery was 1 pound 10 shillings;
preternatural, using forceps, 3 pounds. Other women
assisted their fathers and husbands; one example
being the wife of Dr. Garret Banta of Bergen County,
who acted in a position very similar to our paramedics,
and Elizabeth Haddon, after whose family the town
takes its name, was noted for her skill in preparing
botanical remedies.
In 1786, the Legislature renewed the licensing act
of 1 772, eliminating the requirement that two superior
court judges be present at the examination.
In 1792, Queens College (Rutgers) entered into an
agreement with Dr. Nicholas Romayne and three other
physicians of New York City whereby students who
graduated from his medical school were given the
medical degree which the College was authorized to
grant. By 1816, at least 34 degrees had been granted.
This agreement, although sanctioned by the Medical
Society of New Jersey (1827) eventually was terminated
by action of the New York State Legislature.
It was during this period that Princeton considered
opening a medical school. In 1795, the famous English
physician-chemist, John MacLean, who was practicing
in Princeton with Ebenezer Stockton, had been invited
to give a course in chemistry at Nassau Hall. So suc-
cessful was this venture that for a while the Trustees
;)L. 81— NUMBER 9— SEPTEMBER 1984
713
thought of expanding the project; MaeLean remained
an officer of the college from 1797 to 1812, yet his
efforts made no progress.
In 1816, the Society was reineorporated by the State
and the Board of Censors of the various constituent
societies was instructed to hold three-hour examin-
ations for admission on such subjects as anatomy,
materia mediea, pharmacy, chemistry, physiology, sur-
gery, theory and practice of physic, and midwifery.
Examinations were to be open to the public and the
successful candidate was "granted the privilege of
practicing physic and surgery in this state.” However,
it was not until 1825 that the state legislature finally
conceded to the Society the right to grant medical
degrees, thus placing the Society on a par with Prince-
ton and Rutgers. It was at this period that Princeton
made a second effort to found a medical school, when
John van Cleve, the brilliant practitioner of the town,
gave a series of lectures on medicine. Unfortunately,
his death in 1826 again terminated the project.
Some of the most popular remedies of the period
included nitre, Jesuit’s bark (quinine), numerous
evaeuants including jalop, rhubarb, senna, and aloes;
mercury and antimony, tartar emetic, and cartharides.
At least one New Jersey physician resisted the tend-
ency to large dosage. Lawrence Vanderveer of Somerset
county insisted on prescribing small doses, thus an-
ticipating Samuel Hahnemann’s homeopathy in this
regard. As for charges, phlebotomy cost 1 shilling;
tooth extraction 1 shilling 6 pence; inoculation 7 shil-
ling 7 pence. Charges for medication usually rendered
the bill much higher. In one case, for severe headaches
(impending stroke), Moses Elmer directed the letting
of blood, to be repeated every few days as the patient’s
strength permitted. In addition, a seton was to be ap-
plied to the neck to promote the discharge of pus, and,
of course, calomel to be continued. Contrasting views
on the proper treatment of fevers split the fraternity.
Thus, the same Moses Elmer refused to give a patient
a drop of water until the desperate man managed to
get to a pail of water, drank all he could and having
finally recovered, informed the doctor what had cured
him; on the other hand, Franklin Hoven in an epidemic
of typhus fever, following the more rational teachings
of Sydenham, gave his patient cooling drinks ad
libitum and earned for himself a great reputation.
New Jersey produced a singular character in the
herbalist Peter Smith (1753 to 1816). Although the son
of a physician, and a graduate of Princeton, he elected
to spend his life wandering with his family through
the southern and midwestem states accumulating in-
formation on the virtues of plants from anyone he met.
His “Indian Doctors’ Dispensatory" is a mine of infor-
mation about native medicinals.
Finally, in the interest of the public the Society had
appointed in 1810 a Standing Committee to study
weather conditions throughout the state, correlating
these with current diseases. Organized with John van
Cleve of Princeton as Chairman, the Committee ij
1 820 expanded to include bills of mortality concemir
births and causes of death.
CONCLUSION
In closing this brief resume of the principal even
in our early medical history, I wish to point out son
of the political and other avocational activities whit
engrossed the attention of the outstanding physician
of this period: Oliver Barnet— judge of Common Pled
John Beatty— trustee of Princeton and member of Cot
gress; Moses Bloomfield — abolitionist who freed
slaves on July 4, 1783; William Burnet — member
Continental Congress and judge of Common Plej!
Jabez Campfield— founder of Morris Academy and a
tive in Warren County Agricultural Society; John Co(
dit— member of Congress and founder of Oran)
Academy; Lewis Condict — member of Congress ai,
trustee of Princeton; Samuel Dick — member of Co
tinental Congress and surrogate; Jonathan Elmerl
member U.S. Senate, judge of Common Pleas; Ebenezl
Elmer — member of Congress, judge Common Plea
Jacob Green — founding trustee and vice-president |
Princeton; Thomas Henderson — member of Congre:
and judge of Common Pleas; Moses Jaques— abo
tionist; Lewis Johnstone — botanist; Samuel Ke
nedy— headmaster, Basking Ridge School; Jofj
MaeLean — professor of chemistry and natural histo
and mathematics at Princeton; William Mcllvane
trustee of Burlington Academy; John A. de No
mandie — active in Burlington County Society ft
Promoting Agriculture; Jonathan Odell — member
American Phil. Society; Robert C. Patterson— preside;
of American Phil. Society and professor of mathema
ics at University of Pennsylvania; Isaac Pierson— mer
ber of Congress; Cyrus Pierson— founder of Caldwt
Library; George Ross— trustee, Elizabeth Academi
Moses Scott— member of Congress; Charles Smith-
trustee of Queens College; Nathaniel Scudder-
member of Continental Congress and trustee '
Princeton; John Anderson Scudder— member of Coi
gress; Isaac Smith — member of Congress; James Stra
ton— judge of court; Samuel Swan— member of Co;
gress; Hedge Thompson — member of Congress ar
county judge; Lawrence Vanderveer— trustee. Queer1
College; John van Cleve— trustee, Princeton; Abrahai
VanBuren— trustee. Queens College; and Thomas Wi,’
gins — treasurer, Princeton.
REFERENCES
1 . Cowen DL: Medicine and Health in New Jersey: A Hi
tory. Princeton, NJ, Van Nostrand Co., 1964.
2. Duffy J: Epidemics in Colonial America. Baton Roug;
LA Louisiana State University Press, 1953.
3. Wickes S: History oj Medicine in New Jersey, and i
Medical Men from the Settlement of the Province to 180
Newark, NJ, Martin R Denis & Co., 1879.
4. Rogers FB, Sayre AR- The Healing Art Trenton, N
Medical Society of New Jersey, 1966.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
714
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MSNJ: America’s First and Oldest
Medical Society
Geraldine Hutner, lawrenceville*
On July 23 , 1 766, a group of physicians met at Duffs Tavern in
New Brunswick to initiate the first medical society in the United
States . This group elected officers, set a table of rates and fees,
and signed a 1 4-item constitution to improve the health and
welfare of citizens in the state of New Jersey .
In the 1700s, New Jersey dis-
tinctly was divided into two re-
gions: East Jersey, the Dutch
and English settlement in the North; and West Jersey,
the southern province from Cape May to Burlington.
When the Duke of York gained control of New Jersey
State, he united both sections — forming New Jersey.
Approximately 150,000 people lived in New Jersey,
with 29 percent of the population in the south. There
were 88 physicians in the state in 1766—1 physician
for every 1,500 persons in the north and 1 physician
for every 2,400 persons in the south (Figure l).1
At this time, midway between the French and Indian
War (1758) and the War of Independence, “the batde
against disease was a one-sided affair in which illness
normally triumphed over the doctor’s primitive
weapons of bleeding, cupping, and purging.”2 Phy-
sicians in New Jersey felt they had to help their pro-
fession, to set standards, fair practices, and exchange
medical information. In the book of minutes (Figure
2) from the first medical society meeting in New Jersey,
mention was made: “of the low state of medicine in
New Jersey, and the many difficulties and discourage-
ments, alike injurious to the people and the physician
. having for several years engrossed the attention of
physicians."3
On June 27, 1 766, a notice appeared in the New York
Mercury newspaper stating:
A large body of the practitioners in physic and
surgery in East New Jersey, having agreed to form
a society for the advancement of their profession
and the promotion of public good, hereby request
and invite every gentleman of the profession in the
province to attend a meeting at Mr. Duffs Tavern
in the city of New Brunswick on Wednesday July
23, at which time and place, the Constitution and
Regulations of the society are to be settled and
subscribed.3
On the comer of Albany and Peace Streets, Ne\
Brunswick, at Duff s Tavern, 17 professional men me
for this voluntaiy, organizational meeting. At this tim<
New Brunswick was a center of travel, on direct rout
from New York to Philadelphia; hence, the perfec
meeting place.
As noted in The Healing Art “The men were
prepossessing sight. The few who lived near and wer
inclined to formal dress wore white Geneva bands a
the collar: others appeared in good black broadelotl
with white cravat, ruffled shirt, silk hat, and even
wig — More were dressed as befitted those constantl
in the saddle: dun-colored kerseys, blue broadelotl
coat, linen homespun shirt, wool or yam stockings, fel
hat, plain silver buckle at shoe and knee, and shoulder
*Ms. Hutner is Managing Editor, The Journal. MSNJ.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
718
- I
ew Jersey in 1766, showing:
The boundaries of its 13
counties.
Their population — census of
1784.
The number of their known
physicians.
Founder of the Medical Society
of New Jersey.
Joined later.
Nonmembers.
Igure 1 — A look at the state of New Jersey in 1766, showing
opulation and physician figures.
?ngth hair loose or gathered at the nape with a deer
hong. One or two wore military uniforms.”4
The first order of business at this meeting was the
lection of officers. Reverend Dr. McKean, at age 34,
vas voted president. Dr. McKean, a man of consider-
able fame and respect, studied medicine and theology
ibroad. He was a minister and teacher at St. Peter’s
\ngliean Church, in addition to his duties as a phy-
sician. Dr. Christopher Manlove was elected secretary
tnd Dr. John Cochran was elected as treasurer, for one
rear.
As secretary. Dr. Manlove kept the minutes. The long,
larrow, yellow cardboard book still exists and is at the
ibrary of the New Jersey Historical Society. Fourteen
signatures were affixed to this book entitled, “Instru-
nents of Association and Constitutions of The New
Jersey Medical Society:” Drs. Robert McKean,
Christopher Manlove, John Cochran, Moses Bloom-
ield, James Gilliland, William Burnet, Jonathan Day-
ton, Thomas Wiggins, William Adams, Bemet Budd,
Lawrence V. Derveer, John Griffith, Issac Harris, and
rfJoseph Sackett, Jr.3 Three more physicians arrived at
Duffs Tavern in the afternoon: Drs. Stephen Campe,
•Ebenezer Blatchly, and an unidentified third man (Fig-
'|ure 3).
The newly signed Constitution of this association
listed 14 items to be upheld by the membership. In the
introduction of this document the signers noted,
“Medicine is one of the most useful sciences to man-
kind.” They believed if they were united in a well-regu-
lated society they would improve the health and wel-
fare of every town, neighborhood, and district through
encouraging honesty, integrity, and frankness in all
matters relating to doctors and patients.3 The 14 obli-
gations cover a wide spectrum, but all kept in line with
the Hippocratic oath and the proper practice of medi-
cine. The Constitution laid out the purposes of the
Society and specific functions, with meetings twice
each year and an annual election of officers. The mem-
V HE
R1 S E.
MINUTES.
and
PROCEEDINGS.
of the
N i:\VJ ERSEY I
MEDICAL SOCim
t E stahl ill ied
.III Iv 23. 1 A>6.
»
f
“ -
y \ nwiiif ejtiKi soacMcm Sncntizr.
et Concordia, tmKjuaui eominntti j
/HHHiaa i or nt. * * * x . / » i
* • \hrr< f Qmf./ia/v.
— — — - — \
Figure 2 — The cover of the book of minutes from the first
Medical Society meeting.
bers also agreed to serve the poor, to discourage
quackery, to seek consultations when needed, to im-
prove licensing requirements, and to disseminate
medical knowledge.
The membership then dealt with the question of a
table of fair fees and rates. As the minutes of the meet-
ing noted, “That there was no law or custom through-
out the province for the paying of regulation fees, for
advice, and attendance,” and it was decided that “one
general and unifonu mode of charging” should be in-
stituted.4
It must be remembered that the committee of men
(Drs. Cochran, Wiggins, Blatchly, and Sackett) who
drew up the list of fees had great difficulty: they all
came from different parts of the state and had varying
financial concerns. After much discussion they did
agree on a fixed schedule after noting in the preamble
to this ‘rate card' the following:
The New Jersey Medical Society considering the
state of medical practice in this Government, and
VOL. 81— NUMBER 9— SEPTEMBER 1984
719
Figure 3— Dr. Lawrence V. Derveer, one of the original signers
of the Medical Society Constitution, in 1766.
apprehending that as they have separated them-
selves to a profession that not only deprives them
of many comforts and indulgences ... by being at
the call of anyone, day or night; but also exposes
them to many disagreeable scenes and often to
great dangers from contagious diseases, etc.;
besides the great expense of education and the
many painful years to be employed in preparatory
studies, as well as that of the science itself, they
are in an especial manner entitled to a just and
equitable reward for their services, at least to live
by this their useful profession.4
A sampling of the rates (Figure 4) gives a look at the
most common complaints of that time.
The second meeting of the New Jersey Medical So-
ciety was held on November 4, 1766, in Elizabethtown.
The most important item on the agenda was the prob-
lem with the proposed fair fees and rates schedule. The
New Jersey public felt a specific cost for medical care,
determined in advance, was outrageous and that phy-
sicians were trying to take advantage of the popu-
lation. Backed into a comer, the Society members
abolished the prescribed rates and fees schedule. They
decided each physician could set his own schedule of
rates, as long as he did not exceed the proposed table
of rates.
The membership was not interested solely in eco-
nomic matters at this meeting; they showed concern
for medical and scientific information. The Society felt
the physicians should exchange information, opin-
ions, cases, and other relevant material at all meetings.
Hence, the first paper was read: Dr. Burnet discussed
the use of lancet in pleurisy. The membership then
SAMPLING OF RATES
Call
Cost
£
s
d
An ordinaiy call, up to a mile and a half 0
1
6
Each additional mile
0
1
0
Simple fracture of the thigh or leg bone
with necessary dressing during the
cure
2
0
0
First dressing a wound, including
unguents
0
7
6
Amputation of a leg or thigh
3
0
0
Extirpation of the tonsils
1
0
0
Extracting a tooth
0
1
6
Obstetrical care
1
10
0
Figure 4 — A sampling of the rates.
voted that each member would be required to read
paper or present a case for discussion at every meeting
In fact, history has noted that “learned discussion wa
the 18th century’s device to overcome the scientifi
shortcomings of the age of medicine.”5
The third meeting of this association was held oi
May 5, 1767, in Amboy, and the main topic of dis
eussion was the education of future physicians. In thi:
day and age, medical practice was taught by observa
tion— the preceptor-apprentice method. The Trans
actions from this meeting noted:
Some members motioned that the method of
educating young gentleman for the study of physic
had not been properly adverted to in this Govern-
ment, but very much neglected, greatly to the detri-
ment of the profession. The Society took the same
into consideration, and agreed that for the advan-
tage of youth and honor of the art, that no student
be hereafter taken an apprentice by any member,
unless he has a competent knowledge of the Latin
and some initiation in the Greek. The time for
apprentices serving never being yet settled, though
an affair of considerable importance, was taken
into consideration. The sentiments of the mem-
bers were very different, but finally agreed that no
member do hereafter take an apprentice for less
than four years of which three shall be spent with
his master, and the other way (with his master’s
consent) be spent in some school of physic in
Europe or America It appearing absolutely neces-
sary to fix apprentices fees, the sum of 100
pounds, proclamation money, was agreed upon
being very low, and no more than a bare acknowl-
edgement for board during the above term.6
The apprentice method was advantageous to all in
helping the physician and teaching the student. One
must remember that at this time, one of the first medi-
cal schools in the country, the University of Penn-
sylvania, was just beginning.7
After this meeting the New Jersey Medical Society
grew rapidly, becoming an influential and educational
association for the state of New Jersey and the United
States. The value is inscribed on the seal of the Society,
“I am known throughout the world as one bearing aid.”
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
720
EFERENCES
1. Davidson HA: The Medical Society of New Jersey. Mass
-lysician 28:46-48, 1969.
2. Medical World News: New Jersey marks bicentennial,
.igust 26, 1966.
3. The New Jersey Medical Society: The Rise, Minutes, and
vceedtngs of The New Jersey Medical Society. Newark, NJ,
>nings & Hardham, 1875.
4. Rogers FB, Sayre AR The Healing Art. Trenton, NJ,
Medical Society of New Jersey, 1966.
5. Cowen DL: Medicine and Health in New Jersey: A His-
tory. Princeton, NJ, D. Van Nostrand Company, 1964.
6. New Jersey Medical Society: Transactions, May 5, 1767,
p. 18-19.
7. Marsh EJ: An outline history of the Medical Society of
New Jersey to 1903. Proc NJ Historical Society, January 1942.
!
i
i
tOL. 81— NUMBER 9— SEPTEMBER 1984
721
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
722
'he History of Medical Journalism
s New Jersey
Arthur Krosnick, m.d., lawrenceville*
The history of medical journalism in New Jersey is rich and
illustrious. Linked by the practitioner's eagerness to transfer
information to others .journals and periodicals have become a
storehouse of interesting and stimulating material.
Although journalism is the busi-
ness of managing, editing, or
writing for journals or news-
tipers, the distillation of this concept is the com-
unication of ideas. From Hippocrates to the present,
lysicians and teachers have been obliged to share
jieir knowledge and experience with students and
;ers. The transition from word-of-mouth and show-
ld-tell to electronic communication has been less a
lange in concept than an advance in technology,
mphasis has moved from description and empiricism
pathogenesis, laboratory and clinical testing, elassi-
bation, and specific therapy over the past two-and-a-
ilf centuries in New Jersey, but practitioners of medi-
ne — from the barely trained novices and apprentices
the first half of the 18th century in New Jersey to
ie present scholarly scientists who manipulate
NA— are linked by their eagerness to transfer infor-
ation to others.
ETTERS, ORAL COMMUNICATION, JOURNALS,
ND DIARIES: 1623 TO 1766
Because of the development of language and the use
symbols to communicate ideas, man has dis-
nguished himself from lesser creatures and has made
ant strides from the cave to the computer. The
)oken word was the bridge from practitioner to ap-
rentice, even as it is today. Present-day medical and
' dentific meetings are based on a foundation of lec-
tures and workshops— albeit supported by slides— but
these differ mainly as to the size of the audience.
Colonial practitioners, who were few in number,
used their senses for observation, palpation, and olfac-
tion and auscultation (before and after the invention
of the stethoscope) to make diagnoses and used their
experience and instincts to make therapeutic de-
cisions since the primitive state of medicine and medi-
cal education offered few alternatives. During the col-
onial and pre-Medical Society periods the majority of
“physicians” had not received any formal training. The
“practice of the healing art was chiefly in the care of
the clergy” who were intelligent and well educated:
“Many of them were distinguished for their knowledge
in medicine, and were authors of some of the earliest
medical papers printed in America. In some instances
the schoolmaster also was the physician and surgeon
of the neighborhood. When the literature of the pro-
fession was confined to the few writers of those early
days, it was easy for the student in literature and sci-
ence to furnish himself with the theories of medicine
and practice."1
In the more sparsely settled regions of the colonies,
women cared for the sick; being untrained, they turned
to “medicinal recipes” in their family record books,
many examples of which are stored in the manuscript
collections of the New Jersey Historical Society.
*Dr. Krosnick is Editor, The Journal, MSNJ.
OL. 81— NUMBER 9— SEPTEMBER 1984
J
723
During the colonial period, physicians kept journals
and diaries in which they recorded the dates, services
(house call, phlebotomy, extraction of tooth, and medi-
cines), and fees. This fascinating material points out
the limitation of treatments (bleeding, purging, dress-
ing, and reduction of fractures) and the regular de-
pendence on empirical medicinals with modest con-
cepts of dietary manipulation.
During the slow transition from observation, em-
piricism, and trial-and-error to a “medical science” in
colonial New Jersey, the “doctor’s” major resource for
information was the spoken word. One can imagine
the discussions about the first epidemic in the prov-
ince, which virtually annihilated the Swedes and Eng-
lish in Salem Creek, about the first recognition of
malaria at the end of the 17th century, and the initial
cases of smallpox in 1715 and yellow fever in 1743 in
Burlington. Diphtheria and scarlet fever were New Jer-
sey scourges in 1735 and 1736, although they were not
recognized as such.
Medical information was published in newspapers
and in other nonmedical publications. A newspaper at
the time carried the following item: "In July 1751, was
committed to the care of Dr. Peter Billings, an ex-
perienced physician and man-midwife, and formerly in
the King’s service, the most extraordinary and re-
markable cure that was ever performed in the world
upon one Maiy Smith, single woman. She had been
upwards of 18 years out of her senses (most of the time
raving mad), eating her own excrements, and was com-
pletely cured by him in two months — contrary to the
opinion of all who knew her.”
Modest communications in the form of descriptive
letters probably were the first example of formal medi-
cal writing in those days. An early record of such a
letter, written in 1738 and 1739, and later published
as a pamphlet in Boston, was the handiwork of Rev.
Jonathan Dickinson.
This publication, "Observations on that Terrible
Disease Vulgarly Called the Throat Distemper with Ad-
vices as to the Method of Cure,” was published in 1 740
and doubtlessly represents the first published case
report from a New Jersey physician. Jonathan
Dickinson, a clergyman, theologian, physician, author,
and first president of the College of New Jersey (Prince-
ton University), wrote his first medical publication
when asked about his experiences in New Jersey with
the throat distemper in 1738. At the behest of a pub-
lisher he agreed to describe his observations and treat-
ment. His paper contained a remarkable epidemio-
logical and clinical description of “that extraordinary
disease, which has made such awful desolations in the
country, commonly called the throat distemper.” Ul-
timately the deadly infection was called diphtheria
(1826). Dickinson wrote “in the most plain and fam-
iliar manner” in order to “communicate to you some
of my experiences in this distemper” and “to con-
tribute what I can towards the relief of the afflicted and
miserable.” What an auspicious beginning by a clini-
cian-writer for New Jersey journalism!1
TRANSACTIONS OF THE NEW JERSEY
MEDICAL SOCIETY
America's first medical society was formed at Duffs
Tavern in New Brunswick on Wednesday, July 23,
Figure 1— Dr. Stephen Wickes (1813-1889) edited the Tran,
actions which then were printed in a single volume. D
Wickes also served as 90th president of the Medical Soeiei
of New Jersey.
1766, and was called the New Jersey Medical Society
The Secretary took minutes at this and each subse
quent meeting by hand, and these were careful!
preserved. At its Annual Meeting, May 25, 1875, th
Society voted to examine and publish the old records
Stephen Wickes edited the Transactions from 1766 t<
1859, which then were printed in a single volume. Th
title page. The Rise, Minutes, and Proceedings of th
New Jersey Medical Society, from the original docu
ment, is held in the manuscript collection of the Ne1
Jersey Historical Society.3
The Transactions represented the proceedings o
the Annual Meeting and were highlighted by the Presi
dent’s address; they represent a gold mine of interest
ing and important medical, social, public health, am
governmental and legislative issues. The inaugural ad
dress of the president often contained clinical materia
e.g. the first tumor conference. In the 1785 Trans
actions, a 17-year-old boy was presented to the a s ;
sembly who discussed the removal of a tumor from th
patient’s forearm. In 1787, Dr. William Burnet, wh<
was the second president of the Society, delivered th<
first scientific paper by a member of the organization
“On the Nature and Importance of the Healing Art,
which later was published.
THE NEW JERSEY MEDICAL REPORTER
Unlike the Transactions of the New Jersey Medico
Society, the New Jersey Medical Reporter was the firs
professional journal “devoted to the interests of medi
cal science generally.” It was published quarterly by ; j
very business-like editor, Joseph Parrish, M.D., of Bur
lington, who charged $2 per annum, payable in ad
vance, or $10 for six copies to be sent to one address
Parrish warned that “those who wish to be placed or
our subscription list will please make their remit
tanees without delay.” Volume I, No. 1, was dated Octo
ber 1847 and included proceedings of the New Jersey
Medical Society, committee reports, a rather testy com
mentary against the system of medicine started by
|
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
724
amuel Hahnemann, called homeopathy, and proeeed-
igs of the National Medical Convention held in New
ork in 1846 and in Philadelphia in 1847 (New Jersey
as not officially represented by action of the State
ociety). There is an editorial explaining the reasons
>r publishing the New Jersey Medical Reporter: To
rovide the proceedings of meetings of the Society, to
‘produce papers presented to District Societies, to lay
efore the subscribers a general summary of medical
?ience such as may be obtained from the various
indred periodicals of this countiy and Europe, and
i publish editorials, biographical notices, and other
ems depending on available space. Parrish also wrote
n editorial on the new scientific breakthrough, “Ap-
lication of the Vapour of Sulphuric Ether in Practical
ledicine and Obstetrics.” There also were articles on
Dlints, a ease report (placenta praevia), book reviews,
nd so on.4
In 1850, Dr. Samuel W. Butler, a new graduate from
le Medical Department of the University of Penn-
/Ivania, commenced practice in Burlington and was
ppointed assistant editor of the Reporter. In 1854,
arrish retired and Butler became the editor and
roprietor of the Reporter which he changed to a
lonthly publication. He was so successful as an editor
Iiat “in 1858 he determined to remove from the some-
what provincial quiet of Burlington to Philadelphia, at
pat time, and largely still the professional metropolis
f the country."5 He then made another daring change,
ltering the journal to a national weekly publication
I0<t a copy, $3 per annum) and retitling it. The Weekly
ledical and Surgical Reporter. According to a subse-
uent editor, D.G. Brinton, Butler continued to publish
Ipe Reporter during the Civil War, “when nearly every
ther medical periodical in the country was obliged to
uccumb.”
1HE JOURNAL OF THE MEDICAL SOCIETY OF
EW JERSEY
H. Genet Taylor first suggested a monthly journal in
is presidential address in 1889. In September 1904,
olume 1, No. 1 of The Journal commenced publi-
ation under the direction of the Committee on Publi-
ation, as ordered by the Board of Trustees in July of
aat year. Richard C. Newton, M.D., of Montclair, was
ppointed the first editor.
Some of the reasons for becoming a monthly were:
) to enlist the interest (and membership in the So-
lety) of younger New Jersey physicians; 2) to provide
better means of communication among the mem-
ers; 3) to make the members better acquainted with
ach other, to induce them to attend and participate
a meetings, and to promote a higher grade of scien-
ific work; 4) to collect and print excellent addresses
nd papers; 5) to induce the hospitals and asylums in
few Jersey to prepare and publish better scientific and
jinical reports; and 6) to aid collateral organizations,
.g. state and municipal health boards, the Sanitary
association, and the State Board of Medical Exam-
iners.6
It appears that the reasons have been fulfilled and
ontinue to be valid. During the last 80 years, there
lave been seven editors of The Journal: Richard Cole
Jewton (1904 to 1906); David C. English (1906 to
1924); Heniy O. Reik (1925 to 1933); Alfred E. Shipley
(1934); Frank Overton (1935 to 1940); Henry A.
Davidson (1941 to 1973); and Arthur Krosnick (1973
to present).
The Journal has remained the mouthpiece of the
State Society, but its editors have functioned with in-
dependence and honesty. While the character of The
Journal has changed very little, its style has varied
with the times, reflecting advances in medicine and
science, changes in socioeconomic and legislative cir-
cumstances, and the needs of the members of the So-
ciety.
Older issues are a storehouse of exciting medical
facts that link practitioners through many aspects of
health and science but especially at the moments of
great discoveries or worldly events. Four wars have
intervened during the life of The Journal and the
scientific discoveries have been so numerous as to defy
tabulation in this essay. Names like Ehrlich and Mayo,
items like paper milk bottles and the roentgen ray, and
drugs like sulfa and recombinant DNA insulin, are in
the pages of The Journal.
A number of significant changes have characterized
our present award-winning magazine: 1) an active,
participatory Committee on Publication; 2) appoint-
ment of a highly competent Editorial Board, manu-
script reviewers, and book reviewers; 3) an up-beat,
positive approach to covers, graphics, typography,
readability, and editing; 4) a strong participation by
university-affiliated authors and contributors to
special departments; 5) emphasis on current and fu-
ture trends in health, economies, professional liability,
governmental and regulatory influences, and the role
of the physician and organized medicine in New Jer-
sey’s health care system; 6) a staff with publication
skills at the cutting-edge of the craft; and 7) special
issues.
In 1947, MSNJ started a Periodic Newsletter during
the presidency of Royal A. Sehaaf of Newark with Rich-
ard I. Nevin, emeritus executive director and editor;
this became the Membership Newsletter with a change
from a special-subject publication to a more diverse,
4-page periodical published under the direction of the
Council on Public Relations with Vincent A. Maressa,
executive director, as the editor. In July 1983, the
Membership Newsletter was terminated as an inde-
pendent publication and was incorporated in The
Journal.
PUBLICATIONS AND HEALTH-RELATED
JOURNALS
State Board of Medical Examiners of New Jersey
Annual Report. The First Annual Report of the State
Board was published in 1891. The Board was ap-
pointed July 8, 1890, under “an act to regulate the
practice of medicine and surgery,” which was known
as the Medical Law and was approved March 12, 1881.
The first published report “To His Excellency Leon
Abbett, Governor of New Jersey,” was submitted by
Wm. Periy Watson, M.D., Secretary. It concerned itself
mainly with the imperfection of the law and the ease
with which individuals with bogus credentials become
legalized physicians in this state.7
The first state examination was given on October 10,
0L. 81— NUMBER 9— SEPTEMBER 1984
725
1890, to 1 1 candidates for licensure to practice medi-
cine; 10 passed and were granted certificates. Each
report thereafter contained the scores of the exam-
inees and the institution at which their medical educa-
tion was obtained. The Ninth Annual Report indicated
that 121 candidates were examined for license to prac-
tice medicine and surgery and 97 passed.7
Bulletin of the Academy of Medicine of New Jer-
sey. The Academy, founded in 1911, did not establish
a journal until April 15, 1955. The first Bulletin had
James E. Gardam as acting editor, and served to
provide to the Fellows of the Academy the proceedings
of a symposium on heparin which was given at the
Academy of Medicine on December 16, 1954. The
President was Asher Yaguda, M.D. Some very il-
lustrious scientific speakers and writers were rep-
resented in the Bulletin, which dealt with such timely
subjects as corticotropin (Philips S. Hench, Nobel Prize
recipient addressed this symposium), alcoholism,
highway safety, and fluoridation. The Bulletin ceased
publication in December 1970.9
Public Health News: New Jersey State Depart-
ment of Health. MSNJ President George T. Welch’s
prediction in 1893 that a cabinet-level Secretary of
Health would be appointed early in the 20th century
came true. In 1865, the Legislature appointed a State
Sanitary Commission, and in 1873 created the State
Board of Health. In 1903, New Jersey became the first
state to license municipal health officers and sanitary
inspectors. In 1915, legislation established the State
Department of Health to replace the Board and follow-
ing this, a monthly publication. Public Health News
appeared. This periodical still exists and reports cur-
rent public health data, advice, and statistics.
New Jersey Journal of Pharmacy. The New Jersey
Pharmaceutical Association was the first such or-
ganization in the United States when it was founded
in 1 870. The origin of the Association was a conference
with members of the Essex County Medical Society.
The New Jersey Journal of Pharmacy succeeded the
Proceedings of the Association in 1927 and is pub-
lished monthly.1213
The Country Practitioner or New Jersey Journal
of Medical and Surgical Practice. Published 1879 to
1881 by Dr. E.P. Townsend at Beverly.11
New Jersey Eclectic Medical and Surgical
Journal. Published in New Jersey from 1874 to 1876;
then moved to New York.11
New Jersey State Homeopathic Medical Society.
Published Transactions or Proceedings from 1855 to
1911. 11
The Fountain or Hydropathic Journal. Published
at Morristown in 1846. 11
The New Jersey Association of Osteopathic Phy-
sicians and Surgeons. The Association was or-
ganized in 1901. It published a Bulletin from 1901 to
1963 when it became the Journal of the Association.11
The New Jersey State Dental Society. The Society
has published Transactions or Proceedings since
1870. Their journal was called the New Jersey Dental
Journal from 1912 to 1919; in 1929, the currei
monthly Journal of the New Jersey State Dental Si
ciety started.11
Auxiliary of the Medical Society of New Jerse\
The Women’s Auxiliaiy to the Medical Society of Ne
Jersey was organized at the Annual Meeting in Atlant
City on June 17 to 19, 1926; the name later w;
changed by dropping “Women’s.” Although the Au
iliaiy did not publish a journal, their Primer (The Bh
Book) encouraged the members to read The Jourru
of the Medical Society of New Jersey and the offici
organ of the Women’s Auxiliaiy to the American Med
cal Association called The Journal and published sine
1928. They also were encouraged to read the AM
magazine Hygeia (now called Today's Health).'3 1
September 1948, the Auxiliary Newsletter was ii
itiated and has been published ever since. Present
titled The Shingle, it is published three times a yea
its editor is Mrs. Thomas H. McGlade, and associa
editor is Mrs. Ralph Fioretti.
Health Hints; Junior Health Hints. These pub)
cations were prepared as a public service by the Sul
committee on Public Relations of the Medical Socie
of New Jersey under the editorship of Richard I. Nevi;
Executive Officer. Each issue contained papers ii
tended for classroom presentation.
SUMMARY
The histoiy of medicine, medical education, medic
organizations, and the histoiy of medical joumalisi
in New Jersey is rich and illustrious. Our olde
journals and periodicals are a storehouse of interes
ing and stimulating material which spans two-and-;
half centuries.
REFERENCES
1. Wickes S: History of Medicine in New Jersey and 1
Medical Men. Newark, NJ, Martin R. Dennis & Co., 1879, p
14-15, p. 37, pp. 89-98, p. 234.
2. McClenahan RL: New Jersey medical histoiy in the cc
onial period. Proceedings New Jersey Historical Society, p
362-374.
3. Transactions. Med Soc NJ 1776, pp. 3-4, p. 9, 184:
1859, 1861, 1893.
4. New Jersey Medical Reporter and Transactions of tl
New Jersey Medical Society. Burlington, NJ, 1848.
5. The Medical and Surgical Reporter. D.G. Brinton, M.
(ed). Philadelphia, PA December 1873 to July 1874, p. 6(
6. J Med Soc NJ Vol. 1. Richard Cole Newton (ed). Newar
NJ, September 1904-June 1905.
7. First Annual Report of the State Board of Medical Exar
iners of New Jersey. Trenton, 1891.
8. Saffron MH: A History of the Academy of Medicine <
New Jersey, 1911-1981. Lawrenceville, NJ 1981, p. 3.
9. Bulletin, AMNJ, 1955-1970.
10. Benson DS: Highlights of the history of public heal
in New Jersey: Public Health News 45:165-169, 1964.
1 1 . Cowen DL: Medicine and Health in New Jersey:
History. Princeton, NJ, D. Van Nostrand Company, Inc., 196
12. Cowen DL: Fifty years of the New Jersey journal
pharmacy. New Jersey Journal of Pharmacy 50:14-17, 197
13. Rogers F, Sayre AR- The Healing Art Trenton, NJ, Mec
cal Society of New Jersey, 1966.
726
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
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Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
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P.A.C.E. provides Participating Physicians
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flurozepom HCI/Poche
References: 1. Kales J et al: Clin Pharmacol Ther
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Clin Pharmacol Ther 79:576-583, May 1976. 4. Kales A
et al: Clin Pharmacol Ther 32 781-788, Dec 1982
5. Frost JD Jr, DeLucchi MR: J Am Geriatr Soc
27 541-546, Dec 1979 6. Kales A, Kales JD: J Clin
Pharmacol 3:140-150, Apr 1983 7. Greenblatl DJ,
Allen MD, Shader Rl Clin Pharmacol Ther 21 355-361,
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13 18 22, Jan 1971 9. Amrein R et al Drugs Exp Clin
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patients with recurring insomnia or poor sleeping
habits, in acute or chronic medical situations requiring
restful sleep. Objective sleep laboratory data have
shown effectiveness for at least 28 consecutive nights
of administration Since insomnia is often transient
and intermittent, prolonged administration is generally
not necessary or recommended Repeated therapy
should only be undertaken with appropriate patient
evaluation
Contraindications: Known hypersensitivity to fluraze-
pam HCI, pregnancy Benzodiazepines may cause
fetal damage when administered during pregnancy
Several studies suggest an increased risk of congeni-
tal malformations associated with benzodiazepine use
during the first trimester Warn patients of the potential
risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam Instruct
patient to discontinue drug prior to becoming preg-
nant Consider the possibility of pregnancy prior to
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day following use for mghtfime sedation This potential
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Caution against hazardous occupations requiring
complete mental alertness (e g , operating machinery,
driving) Potential impairment of performance of such
activities may occur the day following ingestion. Not
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age Though physical and psychological dependence
have not been reported on recommended doses,
abrupt discontinuation should be avoided with gradual
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Precautions: In elderly and debilitated patients, it is
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730
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
Preliminary Report of Yellow Fever
During the 18th Century*
William J. Snape, m.d., haddonfield
Edward L. Wolfe, ph.d., pitman
Written evidence suggests yellow fever existed in the 18th
century. The source of infection was watermen who plied the
creeks and rivers to Philadelphia and infected Philadelphia
fugitives who, for prophylactic or therapeutic reasons, sought
refuge in southern New Jersey.
Despite the frequent notice of
those calamitous epidemics of
yellow fever that ravaged Phila-
delphia in the closing years of the 18th centuiy, very
little information readily is available concerning the
effects of this pestilence on neighboring New Jersey.
The several histories of the counties of the lower half
of New Jersey that were published in the last half of
the 19th century make little or no mention of the
disorder.1 3 In spite of such silence, it seemed reason-
able to assume that West Jersey should especially have
been vulnerable to contamination not only because of
its proximity and its social, religious, and economic
dependence upon Philadelphia but also the conse-
quent social interaction between the two communities.
Not surprisingly, a search of representative letters,
diaries, day books, and medical treatises reveals
enough documentation of yellow fever to justify a sum-
mary notice of its effects on the lower counties.
Although some of the outbreaks of the disorder were
sufficiently severe to desolate small settlements along
the creeks and rivers of West Jersey, the inaccessibility
of the records of these outbreaks has led to the ap-
parently reasonable conclusion that the area escaped
the several attacks of the disease even as it ravaged
Philadelphia4 Such a conclusion, unfortunately, is
quite false.
West Jersey, at that time, was composed of the terri-
tory now known as Burlington, Camden, Gloucester,
Cumberland, Salem, and Cape May Counties, an area
of slightly over 3,000 square miles5 inhabited by about
53,000 people.6 Thus, the population concentration
was very low.
In contrast, at the time of the 1793 epidemic, the city
of Philadelphia was confined within an area that ex-
tended only nine blocks along the Delaware River and
did not extend much beyond Independence Hall.7 It
was in this congested, unsanitary area that most of the
susceptible 50,000 population was crowded into
streets, alleys, and courts. About 4,000 persons died of
the pestilence.
Although the sparse settlement of West Jersey surely
inhibited the spread of yellow fever, it did not prevent
outbreaks of the disease.
In 1700, following the first disastrous epidemic in
Philadelphia, there was another milder attack of yellow
fever that killed 40 settlers “on the two sides of the
river," according to William Penn.8
Moreover, Cowen noted yellow fever was present in
Burlington County in 1746, at a time when it generally
was not known to be extant in Philadelphia.9
In 1793, John Hunt’s diary specifically identified
only one case of yellow fever in Burlington County.10
The diary noted that Sara White died at N. Barton’s,
of the “fever.” Two days earlier, however, “10th month,
‘Presented to the Medical History Society ot New Jersey on
May 18, 1983. Correspondence may be addressed to Dr.
Snape, 261 Moore Lane, Haddonfield, NJ 08033.
VOL. 81— NUMBER 9— SEPTEMBER 1984
731
1st day," Hunt recorded that “many people in the coun-
try as well as the city died of the fever.” Again, in 1798,
Hunt noted on September 1 that “the epidemic is very
mortal in Philadelphia and the greater part of the in-
habitants is fled and it is in Burlington . . . and that
it’s at Morrises River very mortal 12 died in 1 1 days
and we hear that divers had died on the highways, in
the woods, bams, and at Moorestown several buried
last week with that disorder.” That Hunt moved from
reporting on Philadelphians fleeing to Burlington to
reporting on the “divers” who “died on the highways”
seems to indicate that some of those who died were
fugitives from Philadelphia Fugitives from epidemics
often could find no habitation for their last hours of
life and expired along the highways, in woods, or in
bams.
Mathew Carey,11 in his brief account of the 1793
epidemic, and Elizabeth Drinker,12 the charming
Quaker diarist, noted the wife and daughter of Joseph
Morgan died of yellow fever at Pensaucon (Penn-
sauken) Creek in what now is the northern portion of
Camden County. The diarist noted another Quaker,
Samuel Cooper’s son, was “dead at ye Ferry," un-
doubtedly Cooper Feny, which was the former name
of part of Camden City. Mrs. Drinker also made men-
tion of the death of “one Vincent M. Pelosi.” Mr. Pelosi
lived at what now is Second and Cooper Streets,
Camden. In the 1798 epidemic, Condie and Folwell
mentioned 26 deaths at Cooper Ferry.13
Haddonfield, which at this time was one of the four
or five villages of this area and certainly was the social
and commercial center, surprisingly has little
documentation of yellow fever. Although there is men-
tion of smallpox, cholera and typhus fever, there is no
mention of yellow fever in the memoirs of Bowman
Hendiy, the physician of the town.14 Yet, Haddonfield
should have been susceptible to the spread of the fever.
There was at least one very busy landing on the Cooper
Creek (now River), and it was on the Feriy Road con-
necting South Jersey to Philadelphia at Cooper’s Feriy.
Moreover, it acted as a transportation terminus for the
surrounding backcountiy.
John Clement, in his scrapbook, briefly mentioned
that yellow fever occasionally was present in Haddon-
field.15 Mathew Carey, in his account of the 1793
epidemic, noted there were infected refugees in Had-
donfield, some of whom apparently expired.11 He be-
lieved that the disease was not transmitted to the local
residents in these instances. Samuel Mickle men-
tioned in his 1798 diaiy: “Some people died at Haddon-
field with yellow fever.”16 Neither Carey nor Mickle,
unfortunately, provided specific details.
Gloucester, now Gloucester City, was at the time of
the epidemics, receding in importance since losing the
county seat to Woodbuiy. We know that at least two
infected refugees were there in 1793. Samuel Mickle
related that one of these unfortunates died. His name
is unknown as are any facts about him except that he
died “back of the schoolhouse.”16 The other refugee
was the Reverend Dr. Robert Blackwell, who was
rominent in Philadelphia social circles. He was the
■ Anglican missionary in West Jersey and served in
A capacity of acting Continental Surgeon and
Ce p. tin at Valley Forge. Despite his confinement in
New .Jersey, he was treated daily by Dr. Benjamin
Rush’s associates. Dr. Rush’s letters regarding hi
treatment are enlightening in regard to the therapy c
the period.17
Woodbuiy and its environs were assaulted by th
fever in 1793, 1797, and 1798. It is uncertain whethe.
there were more yellow fever cases in Woodbury thaj
elsewhere during this period or whether more evidenc
for its existence has persisted. The diarist Samui
Mickle, who had what appears to be morbid in teres
in disease and death, left some details of the pestileni
tial visitation. Not only does his diary provide interest
ing statistics of yellow fever and other diseases, but hi
daybook supplies unusual details of some of the out
breaks. Letters from Dr. William Lummis, of Wooc
buiy,18 and Dr. James Stratton, of Swedesboroughji
give evidence of the local incidence of yellow fever in
Gloucester County. The report of John Otto publisher
in Benjamin Rush’s volume, Inquiries,20 documents
a large outbreak of the disease and its associaten
climatic conditions in 1797 at Red Bank, which is onl
three miles west of Woodbury. Noah Webster21 als-:
described this outbreak that caused at least ten death
in the settlement.22
Mickle documented 18 cases in the 1793 epidemi
in Woodbury and the neighboring county and an equ£
number in 1798. Mr. Mickle mentioned 5 cases oi
Timber Creek, 3 cases at Thompson Point (Paulsboro
Haddonfield, and deaths at Carpenter’s Bridge (Man
tua). He noted that Joseph Sloan, a Quaker, died an
was buried in Newton, some 40 miles away. Accordin
to John Hunt’s diaiy, there were 1 1 deaths at Poi
Elizabeth on the Maurice River. Dr. Stratton describe
outbreaks at Carpenter’s Bridge (Mantua) and at Ole
man Creek. In both cases, the infection was brough
from Philadelphia by watermen.19 Dr. Jonathan Elme
described cases and deaths in Bridgeton, on th
Cohansey River.23 In the 1798 epidemic, Condie an;
Folwell listed 26 deaths of yellow fever at Chews Lane
ing on the Timber Creek.
Fugitives from epidemics
often could find no
habitation in their last
hours of life and expired
along the highways.
One of the interesting theories propounded by D
Rush was that infected fugitives did not communicat
the disease to exposed inhabitants. The following case
seem to cast doubt on Dr. Rush’s theory. In the fall cj
1 797, Dr. John Otto, a Philadelphia physician who ha
family ties in Gloucester County, studied a seriou
outbreak of yellow fever at Red Bank, a farming coir
munity of five families. It is believed that 29 person
sickened and several died. In August of 1 798, Dr. Otf
contracted yellow fever and sought refuge in Woodbui
at the home of Dr. George Campbell.16 Although D
Otto recovered. Dr. Campbell took the disorder an
died. Likewise Mrs. Hopper, who lived near Woodbur
nursed a fugitive from Philadelphia She expired as di
two of her children. Dr. Stratton reported an instanc
where watermen went to Philadelphia froi
732
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE':
arpenter’s Landing. While in Philadelphia they be-
une intoxicated and went into Southwark and helped
lace victims into coffins. They returned to Carpenter's
anding (Mantua) and in four or five days sickened
id died, but not before transmitting the disease to
i?veral others of the community, some of whom ex-
1 red. 19
The 1798 epidemic was characterized not only by its
rulence but also by its extensive spread along the
astern seaboard. Portsmouth, Boston. Newport, New
fork, Virginia Baltimore, and Wilmington were at-
icked by the pestilence. Wilmington was gravely as-
lulted: 252 people succumbed. A Miss Sally Harding
bd from Wilmington to her uncle, a Mr. Peterson. His
ome was in "Cove,” which was about three miles
Dove what is now Pennsgrove, New Jersey. About a
eek later she developed the symptoms of yellow fever
at recovered. Her uncle contracted the disorder and
so recovered after a serious illness. Her nurse, how-
/er, succumbed to the infection, as did one of her
sitors, a Mr. Miller, a medical student.13 According to
jondie and Folwell, there also were cases of yellow fever
. this time in Trenton and Lumberton.13
ONCLUSION
From this review of various primary sources, it is
^parent that yellow fever existed in New Jersey in
793, 1797, and 1798. Some of the outbreaks were
latively severe considering the sparsity of the popu-
tion.
The evidence suggests that the infection was com-
unicated to the population of West Jersey by water-
men who plied the creeks and rivers to Philadelphia
id by infected Philadelphia fugitives who, for pro-
lylaetic purposes or even for therapeutic reasons,
>ught refuge in southern New Jersey.
There is scattered evidence that yellow fever was
resent in New Jersey in the 18th century and con-
ijnued investigation perhaps will reveal it was, eon-
dering the sparse population, quite prevalent.
The lack of recognition of the degree of involvement
West Jersey probably was due to (1) the primitive
ilture and governmental organization at that time;
id (2) the dreadful desolation that involved Philadel-
hia, which was then the medical center of the North
imerican continent, made the outbreaks in South Jer-
sey seem relatively insignificant.
REFERENCES
1. CushingT: History of the Counties of Gloucester. Salem,
and Cumberland. New Jersey. Philadelphia. PA Everts and
Peek, 1883.
2. Prowell GR The History of Camden County. New Jer-
sey. Philadelphia, PA L.J. Richards and Co., 1886.
3. Woodward EM: History of Burlington County. New Jer-
sey. Philadelphia, PA Everts & Peck, 1883.
4. Cowen DL: Medicine and Health in New Jersey. Prince-
ton, NJ, C. Van Nostrand Co., Inc., 1964, p. 41.
5. Murphy JL: Compendium of Censuses. 1726-1905.
State of New Jersey. Trenton, NJ, 1906.
6. Gordon TF: Gazeteer of New Jersey. Daniel Fenton.
Trenton, NJ, 1834.
7. Weigley RF (ed): Philadelphia. A 300-Year History. New
York, NY. W.W. Norton Co., 1982, P. 172.
8. Bronner EB: William Penn’s Holy Experiment. Philadel-
phia, PA Temple University Publications, 1962.
9. Cowen DL: Medicine and Health in New Jersey. Prince-
ton, NJ. C. Van Nostrand Co., Inc., 1961, p. 2.
10. John Hunt Diary, 1788 to 1800, volume 3.
1 1. Carey, M: A Short Account of the Malignant Fever Late-
ly Prevalent in Philadelphia. 4th edition. Printed by author,
1794, p. 81-82.
12. Biddle HD (ed): Extracts from the Journal of Elizabeth
Drinker. 1759 to 1807. Philadelphia, PA J.B. Lippincott Co.,
1889, p. 197, 204, 209.
1 3. Condie T, Folwell R: History of the Pestilence Common-
ly Called Yellow Fever Which Almost Desolated Philadel-
phia. Philadelphia, PA 1798, p. 97.
14. Memoir of Bowman Hendry. M.D. Late of Gloucester
County. New Jersey, by a Physician. Philadelphia, PA King
& Baird, 1848.
15. Clement, J: Sketches of the Village of Haddonfield,
New Jersey. Manuscript, 1844.
16. Mickle S: Samuel Mickle Diary. 1792-1812, p. 38, p.
73, p. 76.
17. Butterfield LH (ed): Letters of Benjamin Rush, Vol I
and Vol II. Philadelphia, PA The American Philosophical So-
ciety and Princeton University Press, 1951, p. 718-723.
18. Hardie J: An Account of the Malignant Fever Lately
Prevalent in New York, 1798, p. 36.
19. Stratton J: Letter to Dr. Joseph Griffitts. Manuscript
collection at Philadelphia College of Physicians.
20. Otto J: Benjamin Rush Medical Inquiries and Ob-
servations. Volume V. Philadelphia, PA Thomas Dobson,
1798, p. 95.
21. Webster N: A Brief History of Epidemics and Pestilen-
tial Diseases. Hartford, CT, Hudson and Goodwin, 1799, p.
319.
22. Mickle S: Samuel Mickle's Daybook of Accounts.
23. Elmer LQC: The Constitution and Government of the
Province and State of New Jersey. Newark, NJ, Martin R
Dennis and Co., 1872, p. 416.
0L. 81— NUMBER 9— SEPTEMBER 1984
733
with Benefits for
a Lifetime
ONCE-DA1LY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
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PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets —
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
hi
80 120 160
LONG ACTING mg mg mg
CAPSULES
Ayerstj
The aopearance of
INDERAL LA
capsules is a registered
trademark of
Ayerst Laboratories.
#18
ONCE-DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE ,
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERALLA iii
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION. SEE PACKAGE CIRCULAR )
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride- Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% ol the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients.
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-ifiduced increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic1
pressure and systolic ejection period The net physpqgic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity.
In dosages greater than required for beta blockade, INDERAL also exerts a qumidine-like
or anesthetic-like membrane action which affects the cardiac ac.UQ.n„gotential . Xhg signtfi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranofot has not beenestabfished Beta-
adrenergic receptors have been demonstrated in the piaf vessels of the brain.
Beta receptor blockade can be useful in conSgjjQS in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital For exampleHh patients wfflTCeverefy
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is Indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride In this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, In some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually Is advis-
' i reinstitute INDERAL therapy and take other measures appropriate for the man-
aoernsni ol unstable angina pectoris. Since coronary artery disease may be
;ogn;zed, it may be prudent to follow the above advice in patients considered at risk
occult atherosclerotic heart disease who are given propranolol for other
indications
NonaM# got Sy.unchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS Wl I H 8RONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking thifj
prior to ma|or surgery is controversial It should be noted, however, that the impaired abi ol
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesti-ia
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of j.
receptor agonists and its effects can be reversed by administration of such agents, | ,
dobutamme or isoproterenol However, such patients may be subject to protracted sti*
hypotension Difficulty in starting and maintaining the heartbeat has also been reportec't
beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevenl the j
pearance of certain premonitory signs and symptoms (pulse rate and pressure change d
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be t
difficult to ad|ust the dosage ot insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroiqr
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symp is
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function t
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have ! ||
reported in which, after propranolol, the tachycardia was replaced by a severe bradycJu
requiring a demand pacemaker In one case this resulted after an initial dose of EjQ
propranolol
PRECAUTIONS. General: Propranolol should be used with caution in patients with imp, i:
hepatic or renal function INDERAL is not indicated for the treatment of hyperter
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Pat
should be told thal INDERAL may interfere with the glaucoma screening test Withdrawal
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart disc
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as ri
pine should be closely observed if INDERAL is administered. The added catecholan
blocking action may produce an excessive reduction of resting sympathetic nervous ac
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthos
hypotension.
Carcinogenesis, Mutagenesis. Impairment ot Fertility Long-term studies in animals I
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studu
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sigmfi
drug-induced toxicity There were no drug-related tumorigenic effects at any of the do:
tevets. Reproductive studies in animats did not show any impairment of fertility that
attributable to the drug.
Pregnancy Pregnancy Category C IKTOERAL has been shown to be embryotoxi
.animal studies atKfpses about IQtimesgreaterthan the maximum recommended human dj
SIS# There are no adequate and wefFcopIrotted studies in pregnant women INDERAL sh
be used during pregnancy only il the potential benefit justifies the potential risk to the fi
Nursing Mothers INDERAL is excreted in human milk Caution should be exercised v\
INDERAL is administered to a nursing woman.
Pediatric Use: Safety and effectiveness in children have not been established.
ADVERSE REACTIONS. Most adverse effects have been mild and transient and t
'y required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive heart failure, intensification of AV block; h-
sion; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usually o
laynaudlype. jm W
Central Nervous System liqMjpadedness; mental depression manifested by insorr
lassitude, weakness, fatigue, reversible mental depression progressing to catatonia; vi
disturbances; hallucinations; an acute reversible syndrome characterized by disorientatio
time and place, short-term memory loss, emotional lability, slightly clouded sensorium,
decreased performance on neuropsychometrics
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarrl
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with acl
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Ftematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopr
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus has b
reported
Miscellaneous alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male in
fence, and Peyronie's disease have been reported rarely Oculomucocutaneous react
involving the skin, serous membranes and conjunctivae reported for a beta blocker (practt
have not been associated with propranolol.
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride
sustained-release capsule for administration once daily If patients are switched from INDEI-
tablets to INDERAL LA capsules, care should be taken to assure that the desired therape
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute
INDERAL. INDERAL LA has different kinetics and produces lower blood levels. Retitration i
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inter
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may
increased to 120 mg once daily or higher until adequate blood-pressure control is achiev
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage of
mg may be required The time needed for full hypertensive response to a given dosag
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDERAL
once daily, dosage should be gradually increased at three to seven day intervals until optirr
response is obtained Although individual patients may respond at any dosage level,
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value -
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few we
(see WARNINGS)
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDERAL
once daily The usual effective dose range is 160-240 mg once daily The dosage may
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is
obtained within four to six weeks after reaching the maximum dose, INDERAL LA ther
should be discontinued. It may be advisable to withdraw the drug gradually over a perloi
several weeks.
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily I
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group are -
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laborator I
8833/.'
Ayerst,
AYERST LABORATORIES
New York, NY. 10017
736
THE JOUFLNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
rHE History of Medicine and
MEDICAL Care in New Brunswick
Norman Reitman, m.d., highland park*
dja ■
II
1
The evolution of medicine in New Brunswick from colonial times
to the present is discussed. A brief history of medical education
as it involved historic Queens College , now Rutgers University ,
is given. The development of health facilities in New Brunswick
is noted.
' "
A
t the time of the 13 original col-
onies, the total number of prac-
titioners of medicine was 3,500.
our hundred practitioners had formal training and
100 of them earned a medical degree. The University
)f Pennsylvania, one of the first medical schools in the
Jnited States, graduated its first class in 1768. There
vere ten graduates, one of whom came from New Jer-
sey. At the end of the 18th century, there were 300
3ractitioners in New Jersey, of whom 41 had earned
nedical degrees.
Three categories of practitioners existed in the col-
onies at that time. The first were those who had earned
degrees in Europe, England, Ireland, or Scotland, and
a few who graduated from the University of Penn-
sylvania The second and most common group were
those students apprenticed to established phy-
sicians who spent a varying period of time with them
jand then went into their own practices, having learned
medicine the pragmatic way. Finally, there were the
(practitioners who, for the most part, were self-trained
and who lived in various outlying settlements and
Jeommunities throughout the colonies and practiced a
sort of herbal or folk medicine.
The first record of a physician in the New Brunswick
area is that of Dr. Henry Greenland who practiced from
1670 to 1706. His office was on the east side of the
Raritan River, in what is now Highland Park. Not un-
common in those days, he also owned a local tavern.
The first course of medical instruction given in the
New Brunswick area was by Dr. Thomas Wood, who
gave a course in osteology and myology in 1752.
DEVELOPMENT OF MEDICINE
The catalyst for the development of medicine in this
area goes back to the French and Indian Wars (1756
to 1763). New Brunswick was the staging area for the
British Expeditionary Force in that conflict. The bar-
racks were at Newark, New Brunswick, Morristown,
and Trenton. The British troops based here were ac-
companied by their medical units consisting of the
medical officers and the corpsmen. They kept the
soldiers who were ill or injured in the barracks, and
for the first time the local physicians saw the modem
medicine of the day practiced by the British Medical
Corps.
On April 14, 1766, in New Brunswick, the Medical
Society of New Jersey was organized at Duffs Tavern,
a well-known landmark on the west bank of the
Raritan River. It was the first medical society in the
American colonies. The Middlesex County Medical So-
ciety also was founded in that same year.
PRACTICING PHYSICIANS
Another significant medical event is associated with
*Dr. Reitman is a Clinical Professor of Medicine, UMDNJ-
Rutgers Medical School.
VOL. 81— NUMBER 9— SEPTEMBER 1984
737
New Brunswick — the licensure of physicians. In those
early days, almost anyone who wished to practice the
healing art could do so. In 1772, Dr. John Cochran, an
outstanding New Brunswick physician in the colonial
and revolutionary period, was instrumental in seeking
the passage of a bill “to regulate the practice of physic
and surgery within the colony of New Jersey” by the
colonial legislature. This represented the first licensing
of physicians in our state. Those who wished to qualify
were examined by the Medical Society and then were
licensed by the Supreme Court of the Colonies.
This was the only licensing body in existence at that
time. Later, the state organized a Board of Medical
Examiners under the Medical Society of New Jersey,
which was responsible for licensing of the physicians.
Dr. Cochran was very active in many other pro-
fessional activities in that era A friend and confidante
of Generals Washington and Lafayette, he eventually
became the Director General of Hospitals for the Con-
tinental Army. He was instrumental in organizing a
smallpox vaccination program in the New Brunswick
area and it is recorded that in 1774 he vaccinated 400
people in New Brunswick with no deaths. He also
served as the third President of the Medical Society of
New Jersey.
Other prominent New Brunswick physicians during
the Revolution were Drs. Moses Scott and John Van
Cleve. Dr. Scott served as Chief Surgeon of the Con-
tinental Army Hospital in Piscataway. Dr. Van Cleve,
a Princeton alumnus and trustee, attempted to estab-
lish a medical school at Princeton; he died before his
ambitions could be realized.
Dr. Charles Smith was the first student to get a
medical degree from Queens College in 1 798. He later
became a trustee of Queens College, which in 1825
became Rutgers College.
An interesting personality during the 1840s was Dr.
Augustus Taylor, practicing physician, mayor of New
Brunswick, and certified sea captain who sailed
around Cape Horn to California and the west coast of
the Americas many times. In his diaiy of March 3,
1838, he speaks of “establishing a dispensary for the
purpose of prescribing and furnishing medicine gratu-
itously to the poor.” He quotes the famous English
physician, Suydenham, who said “the poor were his
best patients because God was their paymaster.”
In 1850, another local physician. Dr. Hollingshead,
was concerned about the fate of the insane and estab-
lished an asylum for the insane under state or munici-
pal auspices. This was the forerunner of today’s State
Department of Institutions and Agencies.
In 1885, Dr. Hemy Rutgers Baldwin founded the
Wells Memorial Hospital which was later to become
Middlesex General Hospital and in 1907, Dr. Francis
Donohue with Monsignor O’Grady founded what today
is St. Peter’s Medical Center.
HOSPITAL CARE
The development of hospitals in this area is interest-
ing. Records show that in April 1872, the City Council
considered a New Brunswick Hospital Board but it
never materialized. In the same year, the Franciscan
Sisters from Loretto, Pennsylvania, came to New
Brunswick and established St. Peter’s General Hospi-
tal. The hospital was closed for economic reasons after
two years; however the building was re-opened as an
orphan asylum and home for the aged several years
after that. In 1884, a New Brunswick City Hospital was
started as a contagious disease facility where patients
could be kept when they had infectious diseases. The!
following year when the Wells Memorial Hospital was
built on Somerset Street, the New Brunswick City Hos-i
pital became part of the Wells Memorial Hospital. The
original Wells building stood on the site of the present'
Robert Wood Johnson Tower of Middlesex General-;
University Hospital and for years was known as the!
Wells Building. It served as part of the hospital facility
as recently as 1968.
In 1907, St. Peter’s General Hospital was founded
and minutes of the trustees’ meetings exist from that;
time. In 1917, Wells Memorial Hospital became the
Middlesex General Hospital; in 1926, the Brown Street
addition was built, giving Middlesex 100 beds. In 1929,
St. Peter’s General Hospital moved to its present lo-
cation on Easton Avenue, opposite Buccleuch Park,
constructing a modem facility of 220 beds. This was
the total number of hospital beds the community had
until the mid-1950s when the first joint hospital drive
took place. The need to expand both hospitals at the
same time prompted the local leaders to organize a
combined drive for both institutions. As a result,
Middlesex Hospital built its 1958 building which in-
creased the bed capacity to 225. Although considered
the most modem facility at the time, it quickly be-
came inadequate and the need for more beds became
evident. St. Peter’s Hospital built its B and D wings,
giving them an additional 100 beds. In 1969, a second
combined hospital drive was conducted which resulted
in the Robert Wood Johnson Tower addition to Middle-
sex Hospital, housing a modem laboratory and many!
more beds. St. Peter’s Hospital, likewise, built a new
operating suite and another wing for patient care, as j
well as updating the facilities for its well-known de-
partment of radiology.
To complete the record, we have evidence of a corpor-
ation in New Brunswick called the New Brunswick
Affiliated Hospitals, which existed from 1965 to 1980.
In the early 1960s, local hospitals conducted medical
residency training programs. These programs were in
danger of losing their accreditation because of insuffi-
cient numbers of beds and subspecialty services at
each institution. A group of physicians, Drs. Gabriel
Piekar, Jasper Van Aveiy, Paul Jennings, and myself
undertook to establish a program to operate a com-
bined medical residency. This joint program had
enough beds and subspeeialty strength for approval.
To facilitate this program, we incorporated under the
name of the New Brunswick Affiliated Hospitals. For
some time, people thought that indeed the two hospi-
tals in New Brunswick were going to combine into one
unit but this never came to pass.
The New Brunswick Medical Residency Program
functioned successfully; later, it merged with the medi-
cal residency programs of UMDNJ-Rutgers Medical '
School. These programs have become highly successful
academic training programs at both institutions.
In 1976, Middlesex General Hospital became the pri- !
mary teaching hospital of UMDNJ-Rutgers Medical
School. Today, Middlesex General-University Hospital
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY!
738
ands as a first-rate academic health science center
jmbining traditional programs of a community hos-
jital, and bringing outstanding health and research
.icilities to the central New Jersey area
The role of Johnson & Johnson must be mentioned,
eeords of St. Peter’s Hospital from 1913 reveal an
<pression of thanks to Johnson & Johnson for sup-
lying all the bandages and dressings free of charge,
or years, the company supplied both hospitals simi-
irly. Johnson & Johnson was the leading force to
ilarge and equip these hospitals and was mag-
animous in promoting education in health care in
lis area
[EDICAL EDUCATION
In 1792, a well-known practitioner in New York City,
r. Nicholas Romaigne, petitioned Queens College to
rganize a medical faculty in New York. He had been
n the faculty of the College of Physicians and Sur-
eons of Columbia University but desired to establish
nother institution. As a result, Queens College
warded several medical degrees between 1792 and
j798. The school then closed but was re-opened in
|812, again under the leadership of the same Dr.
omaigne. It was known as the Queens College Medical
'epartment and graduated 21 physicians between
812 and 1816. In 1825, Queens College became
utgers College, named after a benefactor, Colonel
enry Rutgers. Once again, the Rutgers Medical Col-
ge flourished under the leadership of Dr. David
(osack, a distinguished professor from the College of
hysicians and Surgeons. The institution awarded 27
ledical degrees from 1826 to 1827. In that year, the
j'.egents of the State of New York forbade the issuing
f degrees from a college or university that was not
jcensed in that state. From 1827 until 1954, there was
no formal medical education in New Jersey although
an attempt to establish a medical school in Newark in
the 1940s failed.
In 1954, the state legislature supported a bond issue
to establish a medical school at Rutgers. This was
defeated. However, the momentum to establish a medi-
cal school in New Brunswick continued. In 1961, the
Kellogg Foundation awarded Rutgers $ 1 ,000,000 to de-
velop a two-year medical school program. In 1962, Dr.
H. DeWitt Stetten, Jr. was appointed dean and began
assembling a faculty. The first class of 16 students was
admitted in 1966. Rutgers, the State University, now
had its own medical school. An excellent basic science
faculty was recruited but plans for clinical facilities
and the development of a University Hospital were
curtailed when the state legislature in 1970 approved
a bill establishing a separate College of Medicine and
Dentistry with one component in Newark and one at
the Busch Campus of Rutgers. In that same year, the
school expanded to a four-year curriculum, graduating
its first students in 1972. This institution, now known
as the University of Medicine and Dentistry of New
Jersey, has grown dramatically in the past 14 years
and the Rutgers Medical School component has grown
with it. At the present time, there is a student body
of over 400 and a large preclinical and clinical faculty
based in Piseataway and New Brunswick.
CONCLUSION
New Brunswick— the hub of New Jersey— is poised
at the beginning of its fourth century. I am sure that
the succeeding years will continue to reveal further
achievements by outstanding New Brunswick phy-
sicians and institutions to the development of medi-
cine that reaches far beyond the city.
i
VOL. 81— NUMBER 9— SEPTEMBER 1984
739
The Life and Times of Camden
■, :
Sam Ale witz, ph.d., Gloucester township*
In the late 19th century , public health programs in Camden city
Cnm/Jnn /t/iifnfft f nn I sir* si s>s*s\r* sim-S s*
lit Lliv ivCtw x c7lli Cvf itiif y f I IviXltf 1 jpf tiy i til I lo (li wtillitivli Clvjj
and Camden county were dependent on political and economic
experiences. Because of this, disease was commonplace , living
j __ • « « | j* .
IC/i OvCiltiJv ty IfiiOf Ulovdov U/Uo CUifiii lUf (J/IUCvf nv
conditions were precarious, and poor health was the norm.
i'i
Camden county public health
programs in the late 19th cen-
tury were dependent on political
and economic experiences. The speed, thoroughness,
permanency, and universality with which these pro-
grams were implemented may be used as an indicator
by which to gauge the sincerity of those politicians and
community leaders responsible for the implementa-
tion.
Mortality rates were a partial measure of the success
of public health activity. They were a useful statistical
reference point but did not describe adequately the
lack of humanity or the quality of life which affected
the health of many of the county residents. While the
entire community suffered from the lack of public and
private hygiene, the poor generally were the most
susceptible victims. They had few friends in public
service, private charity, and in the professions. The
county and city medical societies were responsive to
the public health needs of the community when dis-
ease threatened and, at critical moments, served to
arouse the politicians to take positive action; however,
they did not sustain these activities over extended
periods of time.
CONDITIONS IN CAMDEN
The public health projects which were undertaken
in Camden county and Camden city before the
mid- 1 880s were restricted to the most basic and primi-
tive sanitary measures. Public and private welfare was
doled out reluctantly and with apprehension. The
meager charity provided to the poor resulted in a
subsistence standard of living which left them in poor
health and exposed to the ravages of disease.
Buttressed by social, economic, and medical mis-
representations and myths, Camden county and mu-
nicipal officials, with the public’s approval, were indif-
ferent to the needs and often dangerously negligent in
their duty to provide basic hygienic and health ser-
vices. The officials ignored the high death rate and,
optimistically, expected that the excellent geographical
location of Camden, the absence of overcrowded tene-
ments, economic growth, and greater employment op-
portunities would serve to provide good health.1'4
Camden public officials tended to minimize the ex-
tent of the risk from threatening diseases and did
nothing until it often was too late. Endemic smallpox
and enteric diseases, for which there were known pre-
ventives, generally were ignored until they reached
epidemic proportions. Only the fear of a dreaded
cholera epidemic moved county and municipal officials
to institute temporary and aggressive public health
measures. The lack of attention to the unsanitary con
ditions and to fundamental humanity was evident in
*Dr. Alewitz earned his Ph.D. in the History Department of
Case Western Reserve University in Cleveland, Ohio, after he
retired as an engineer who had devoted his career to the
improvement of the quality of life and safety in the home.
740
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
a number of events which occurred from the end of
1879 until about the middle of 1881.
Camden city, with an area of 6.5 square miles, had
doubled its population from 20,045 in 1870 to 41,659
in 1880. Camden was the 4th largest city in the state
and the 44th in the United States. Over 9,900 people
'lived in the next three largest towns and 13,257 lived
in 222 square miles of rural countryside. Approximate-
ly 85 percent of the population was native born; of the
17,166 foreign born, most were from England, Ireland,
land northern Europe. Kaighnsville, a neighborhood of
jCamden city, had an expanding black community and
other black communities were established in sur-
rounding townships. There was a black population of
5,652, approximately 9 percent of the county popu-
lation.56
Camden county served as a home for thousands of
commuters who worked and shopped in Philadelphia.
It also attracted a great many transients, without any
prospect of employment, who brought with them
potential health problems.6
The businessmen and politicians had envisioned the
growth of Camden county into a prosperous industrial
metropolis. However, the adverse economic conditions
of the 1870s caused many Camden county workers to
have serious doubts about their future. The New Jersey
Bureau of Statistics of Labor and Industry reported
that New Jersey unskilled workers earned $412.35 a
year, and skilled workers earned $625 a year. However,
(expenses for a family of five were in excess of $618 a
year; a condition which forced many of the Camden
workers into debt and left a trail of broken homes.7
Hunger was commonplace and starvation was ac-
knowledged publicly. The editor of the Camden Daily
Post was disturbed by the presence of starvation in
Philadelphia and aboard ships carrying immigrants to
the United States, but reported, without any emotion
or bitterness, starvation in Camden county.28 James
Bishop, Chief of the Bureau of Statistics, called the
payment of low wages an “abominable doctrine" that
led “to strife, poverty, crime, and general demoraliza-
jtion,” and attributed the hard times in Camden to an
unequal distribution of wealth.9 Dr. Ezra M. Hunt, sec-
retary of the State Board of Health, further charged
that the wage question was not only a problem of pay
scale, but the ability of a worker to purchase good
health.10
PUBLIC AND PRIVATE CONCERNS
In 1880, there were few public or private organiza-
tions in Camden county to which the needy could turn
for help. In the public sector there was the county
poorhouse and meager municipal outdoor relief.28 In
1879 and 1880, the city of Camden reduced its welfare
funds from $13,000 to $200. Even with these sharp
cuts some residents remained as fearful of relief
“cheaters” who, they claimed, would squander these
scanty funds as they were of the city employees who
had access to these funds.23
Gloucester city reluctantly allocated $750 for welfare
funds for the year 1880. However, they let it be known
that the $10,000 paid in taxes to the county provided
adequate funds to take care of their poor.2 1 Responsi-
bility for the burial of the poor, the last act of charity,
was a contested issue between the county and
Gloucester city, with each refusing to provide the
necessary money. There is no evidence that any of the
other communities made a more generous contribu-
tion for the care of their destitute residents.24
The Camden Daily Post was commended by a group
of the “most discriminating citizens" for supporting
their position on public charity. This group was con-
vinced of the "shameful waste” of public aid to the
poor.2 This position was not unusual and was in ac-
cord with the generally accepted social theories of the
period; indiscriminate charity led to pauperism and
moral and physical degeneration, which gave rise to
hereditary defectives.2 In a letter to the editor,
"Benevolence” expressed the consensus opinion and
declared that “the only way to relieve the worthy poor”
was through “private benevolence and not with public
funds."2
In spite of the appeals for private charity, when the
State Charities Aid Association of New Jersey was or-
ganized, in 1886, to develop acceptable ways to dis-
pense aid to the needy, Camden county was not rep-
resented.2 4 Private philanthropy in the county was lim-
ited to orphanages, soup kitchens, sewing groups,
Sunday breakfast missions, and personal almsgiving.
However, private charity was not offered freely. It was
necessary for the press repeatedly to appeal to the
humanity of the residents of the county to care for the
indigent.24
On January 16, 1881, the Philadelphia Times,
without mentioning Camden by name, wrote that
there was nothing so pathetic in the world as men and
women who were “half sinking in that sea of troubles
which is the result of continued poverty.”8 On January
19, 1881, the West Jersey Press accused the Philadel-
phia newspaper of attempting to blackmail the
Camden City Council for the purpose of “relieving the
suffering poor.” The paper rationalized that it would
be sheer coincidence that with over 40,000 inhabi-
tants there would be no “want and suffering" and,
furthermore, the money was ending up in “pockets of
a certain class of officials.”3 Camden’s policy towards
the poor made the private city of Philadelphia appear
generously philanthropic.
SANITARY CONDITIONS
The sanitary conditions in Camden county were
primitive. As late as 1886, Camden city, with 60 miles
of dedicated streets, reported that only 1 mile was
paved in Belgian and asphaltum block; half of the
streets were crudely paved, and the remainder of the
streets unpaved.56 However, telephone service in
Camden city was operative on August 15, 1879, more
than a year before the first Belgian block pavement was
laid in Federal Street in 1881. 2 12 Only paved streets
were contracted to be cleaned, so that approximately
59 miles of streets remained quagmires of filth from
overflowing cesspools, culverts, and clogged sewers.
Portions of the Seventh and Eighth Ward, where the
poor lived, never were cleaned. Pigsties were kept in
backyards, animals roamed the streets ireely, and the
hundreds of horses used for transportation mid
cartage added to the danger of an already unhealthy
environment.236 13 Poorly designed and const meted
sewers and culverts became elongated cesspools that
VOL 81— NUMBER 9 — SEPTEMBER 1984
741
festered in the summer heat.13 Residents of com-
munities with inadequate drainage were plagued with
“remittent" fever (malaria). Raw sewage and polluted
run-off water were carried into the Delaware River and
created a noisome nuisance. Sewage moved upstream
by tidal activity from Camden sewer outlets and across
the river from Philadelphia into the Camden water
supply. The enteric diseases which arose were called
“Kensington Diarrhea” in honor of the Philadelphia
source of the scourge.2 46 The communities which were
not sen/iced with city water mains were not exempt
from these dangers, since their seldom emptied
cesspools contaminated the well water.6
Gloucester city, with a population of 5,347, the sec-
ond largest city in the county, was just as unsanitary.
A report in the West Jersey Press described the city
as follows: “The gutter with its concomitant filth lies
stagnant and festering, polluting the air around and
inoculating with noxious diseases all who have oc-
casion to pass through the streets.”3
The public health projects
which were undertaken
before the mid- 1880s were
restricted to the most basic
and sanitary measures .
Housing in Camden, which had a low density of 5.1
persons per home, had been compared favorably by the
members of the 1874 New Jersey Health Commission
with conditions in Philadelphia, known as the “City of
Homes;" while the tenements in Newark, Jersey City,
Paterson, and Trenton were compared with the over-
crowded and unsanitaiy housing of the lower east side
of New York City.14 What is significant is that Camden
had a death rate of 22.9 per thousand, a rate equal to
any of the more populated and overcrowded northern
New Jersey cities.6
The Camden housing statistics did not paint a re-
alistic picture of housing conditions which existed in
the city. Dr. James H. Wroth, in The Physicians Dis-
pensary Report described Kaighnsville, a section of
Camden city, as crowded, with families occupying one
room which was used for sleeping, eating, and cooking;
with no drainage or sewerage system; with water
pumps on the street comer near open culverts; and
garbage strewn over the unpaved streets.215 Sections
of Camden city were repositories of antiquated single
homes, long in disrepair, which were inhabited by the
poorest classes of native and foreign bom. In 1890,
Hunt pointed to the bad housing as a cause of “de-
gradation, thriftlessness, sickness, and crime.”16
In the county and its political subdivisions, public
health agencies were nonexistent or noneffective and
private medical care was limited. The Camden City
Council had established a Sanitary Committee in 1872
but its activity was restricted by local politics. In 1886,
the city reluctantly established an independent Board
o; Health under the direction of a physician but only
at the urging of the medical societies and after an 1 88 1
amendment to the state public health law made it
mandatory.2-3-617
MEDICAL CARE
Medical care for the poor of Camden county was a
story of tragic neglect. It was only through the work
of a few charitable individuals that even the most rudi-
mentary health services were provided. On April 1,
1866, through the efforts of several local businessmen
and physicians, a Camden City Dispensary for the
"worthy" poor was opened under the management of
the Camden City Medical Society. Several years later,
a few beds were added as a hospital for the indigent,
and to provide emergency services. However, the hospi-
tal section soon was closed due to a lack of funds.17
The Dispensary continued to have a turbulent history:
ignored by the county, neglected by the city, and
spurned by the public in its efforts to raise funds, only
the charity of a few physicians provided the services
and money to continue their good works.2-317 In 1879, \
after it became obvious that the Dispensary would be
forced to close, the city agreed to provide minimum
funds for drugs and physicians’ services.3 17 Too many
died without any medical assistance and as late as j
1881, after the city had agreed to pay for some of the
services, the Camden Daily Post noted the inadequate
medical care provided to the Third Medical district
which comprised the Seventh and Eighth Wards, home
to many of the indigent and working poor.2
The Cooper Hospital, endowed by the Cooper family,
was incorporated on March 24, 1875, and completed
in 1877; however, due to a lack of funds, it was not
opened to the public until August 1 1, 1887. On Febru-
ary 5, 1885, the homeopathic physicians, who had
been criticized frequently by the Camden County and
Camden City Medical Societies, opened a small hospi- 1
tal comprising two wards as well as an outpatient de-
partment. Since private efforts were directed toward
the “worthy” poor sick, it remained for the county to
provide a “hospital” at the Almshouse for the “un-
worthy” poor, and this was opened after the typhus
epidemic occurred at that county institution.17
The social upheaval of the Civil War and the subse-
quent economic depression of 1873 created an army
of transients, many of whom found their way through
Camden county because of its crossroad location. They ;
brought with them the seeds of disease and ill health ;
and served as a focal point for arousing fear, hatred, j
and mistrust. As living proof of the failure of public
relief, they were housed in the local jails and county
almshouse at the expense of the taxpayers who were
averse even to paying for the care of the resident poor.
Dr. Hunt, in a study of the problem, estimated that the
cost to Camden county was in excess of $20,000 for
the period of the typhus epidemic of 1880 to 1881. 6
On October 28, 1879, the Syracuse Times made a
startling discovery. It found that the average citizen of
New Jersey lived longer and suffered less from sickness
in prison than while at liberty.2 It is highly improbable
that the allegations applied to the unsanitary and un-
savory Camden county jail which had been under at- i
tack as a menace to the health of the prisoners since
1876. In May 1879, the matter was presented to the
grand jury which handed down an indictment that
charged the Board of Chosen Freeholders with main-
taining a jail that was “unwholesome, ill-governed,
overcrowded, unfitted, and inadequate.”2'4 18 Long after
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
742
his visit to the jail. Dr. Hunt gave vent to his anger and
described the conditions as follows: “Garbage long un-
emptied, beds and cells beyond description, linen un-
changed for months, not a towel seen by inmates, and
the general condition of the dungeons, the corridors,
and the inmates, made it a scene scarcely to be credited
but for the number and character of the witnesses.”
In addition to strong ideological reasons for denying
support to the poor, the behavior of the politicians,
press, and many residents stemmed from their con-
scious efforts to reduce county and municipal ex-
penses. Nowhere was this more obvious than in the
actions taken toward those most dependent on the
bureaucracy for medical help and humanity: the men-
tally ill.
THE COUNTY ASYLUM
The County Asylum was opened in 1879. It was es-
tablished in order to save approximately $6,000 per
year by removing county residents from the more
costly Trenton State Hospital.238 The position of the
Freeholders was that since the County Asylum was to
be used for incurable patients that it would not be
necessary to provide a full-time physician or a pro-
fessional staff. From the veiy inception of the project
the County Medical Society refused to give its whole-
hearted approval. Dr. Dowling Benjamin, a member of
the Society Asylum Committee, voiced his doubts and
disapproval, and Dr. J. M. Ridge, who had served as a
member of the New Jersey State Board of Health, had
given tentative approval to the establishment of the
County Asylum, but finally called the idea “a false
measure of economy.”2'4-8 However, the move was ap-
plauded by the politicians and business community.
Their delight was short lived when rumors of alleged
mismanagement and cruelty at the Asylum and
Almshouse surfaced and exposed conditions at the
institution, to the scrutiny of the public.
On or about October 1, 1879, the Reverend William
H. Jeffreys, a Methodist Episcopalian minister with 25
years of service, suffered a nervous breakdown and was
admitted to the Camden County Asylum. On October
5, 1879, Nathan T. Mulliner, a well-known and respect-
ed Camden businessman and a member of the
Camden Masonic Lodge No. 15, which listed among its
members many well-known Camden physicians, was
found wandering aimlessly in Trenton. He was re-
turned to Camden and admitted to the Asylum. At the
time of their admissions, rumors of misconduct and
mismanagement at the Almshouse and Asylum sur-
faced but summarily were investigated and dismissed
by the Board of Chosen Freeholders.23
A few months later the editor of the Camden Daily
Post found reason to suggest that there was little to
I fear since “the days of darkness, dungeons, whips, and
chains of lunatics” were over.2 In spite of his asser-
tions, the rumors of inhumane treatment at the
Asylum continued to persist and the paper featured a
story, “Our Poor and Insane,” which detailed a visit by
local politicians and physicians to the Asylum. The
report included support for the Asylum management
and a diagnosis made by Mrs. Stiles, the matron
(supervisor), that most of the patients were confined
because of paralysis of the brain brought on by in-
ordinate use of tobacco and rum. At the conclusion of
their visit, the visitors ate a hearty meal which was
provided by the Asylum, no doubt topped off with
cigars and wine, “and the gentlemen then went over
the hill to the poorhouse for a visit.”2
After his release from the Asylum in November 1880,
Jeffreys publicly charged that the patients were sub-
jected to cruel treatment at the Asylum, and specifically
called attention to the beating administered to
Mulliner. Because of their social positions in the com-
munity, his charges triggered a new series of inquiries
into the allegations of mistreatment. On Januaiy 8,
1881, Masonic Lodge No. 15 appointed a committee of
its members to investigate cruelty at the Asylum and
mismanagement at the Almshouse. The report never
was made public.28 The following day, the Philadel-
phia Times accused the officials of the County Insane
Asylum of conducting an institution with conditions
they labeled as “madhouse inhumanity.” They alleged
that the Asylum personnel was guilty of beating the
patients with blackjacks, and that the general con-
ditions were worse than the “filth, foul air, and fatal
fever” at the Almshouse.8
As a result of the charges which were leveled by the
Philadelphia Times and the undercurrent that rip-
pled outside of the county boundaries, two Boards of
Inquiiy were established. The Board of Chosen Free-
holders appointed a committee which included two
members of the Asylum Committee, and members of
the Joint Committee on Lunatic Asylums of the state
legislature constituted the second committee.248 The
investigating committees were established as volun-
taiy bodies, without legal sanction, and it became ob-
vious that the charges made by Jeffreys would not be
sustained. Twenty-eight witnesses were heard in three
hearings. Only 3 of the witnesses had been patients,
and 1 was the wife of a patient. Unfortunately, those
most directly involved were not able to testify because
of their mental condition.81920 In the end the Board of
Chosen Freeholders exonerated itself, while the state
committee, more politically astute, issued a report that
found the problem of maltreatment due to inexperi-
ence rather than inhumanity, and further recommend-
ed that patients first be sent to the Trenton State
Asylum for treatment before being declared incur-
able.2,4'2021
The results were greeted by the Camden press with
a display of hometown partisanship. Before the final
reports were issued, the local press displayed some
concern for the therapeutic needs of the patients and
the welfare of the residents of the county. The West
Jersey Press clearly had enunciated the public view:
the Asylum was badly managed, “acts of cruelty were
common and drunkenness frequent,” and the in-
vestigation proved the Freeholders “incapacity" and
“unfitness” to run "an institution for which some
ideas of humanity" were essential requirements.3 The
state legislature, aware of the problems in the Camden
Asylum and in anticipation of the final reports, in-
troduced an act to reform the management of county
asylums. They concluded that it would “not do to trifle
with life and intellect simply to save a dollar or two."2
THE ALMSHOUSE
The conditions mid inhumanity at the Asylum were
VOL. 81— NUMBER 9— SEPTEMBER 1984
743
not an isolated case of neglect by public officials. The
exposure of the conditions at the Asylum had been
preceded by a smallpox epidemic that raged in Camden
city and a typhus epidemic at the Almshouse. The
politics of neglect, aided by socioeconomic conditions,
and adverse weather, helped turn the Almshouse into
a death trap. The extreme cold temperature of Novem-
ber 1880, drove the transients in Camden to seek ref-
uge in the local jails and the Almshouse.2 The
Almshouse, built to house about 150 residents, held
approximately 275 men, women, and children. More
than a year earlier, complaints had been leveled at the
Freeholders for allowing the overcrowded conditions,
with the potential for disease, to exist.3419 On July 1 1,
1879, at a special meeting of the Freeholders, plans
were approved for a needed addition to the Alms-
house.322 Unfortunately, the building was not finished
in time to help the victims of the typhus epidemic that
began at the end of November 1880.
On November 4 or 5, 1880, Hemy Brown, a transient
laborer from Philadelphia who had worked in Ellisburg
(a crossroad village in Camden county), visited his
hometown where he roomed in an overcrowded, lice-
infested boarding house. On November 1 1 he returned
to Ellisburg. On November 24, Brown, running a high
fever and in a semiconscious state, was brought to the
Almshouse. His condition was diagnosed as “malarial
fever,” and because there were no other facilities avail-
able, he was placed in a 12 by 12 foot room with three
other residents who soon contracted the disease,
which then spread throughout the Almshouse. On De-
cember 23, the heating boiler, in the new building
which had been rushed into service as a hospital, burst
and the rooms had to be evacuated because of the cold.
This forced the already overcrowded patients and resi-
dents into even closer quarters.617
On Januaiy 8, 1881, the Philadelphia Times pub-
lished the first of a series of articles condemning the
county officials for creating “a Poor House Plague, of
filth, foul air, and dying paupers.”8 With 47 sick and
1 1 dead, the paper lashed out at the unsanitary con-
ditions and the inhumane treatment of the Almshouse
residents. There were suspicions that the disease was
typhus fever, on the basis of pathological studies per-
formed by Drs. Henry E. Branin and Joseph W.
McCullough. However, Drs. Branin and McCullough,
part-time physicians at the Asylum and Almshouse,
respectively, continued to address the problem as a
“serious and malignant epidemic marked with charac-
teristics of typhoid, typhus, and malarial fever.”6
Tophus was not confirmed until E. A. Ward, the con-
tractor for the new addition and a well-known poli-
tician, was fatally stricken with the disease while at
work at the Almshouse. Dr. William Pepper of the Uni-
versity of Pennsylvania was called in as his physician
on January 11, 1881, and diagnosed the disease as a
virulent typhus. An autopsy performed by two
pathologists, Drs. James Tyson and Henry F. Formad
from the University of Pennsylvania, later confirmed
Dr. Pepper’s diagnosis.223
On Januaiy 17, 1881, Dr. Hunt visited the Alms-
house at the invitation of Drs. Branin and McCullough.
He inspected the Almshouse drainage and water sys-
tems, a normal first step for disease control. His survey
did not result in any change in the conditions that
prevailed at the institution. On February 3, Drs. Hunt
and F. Gauntt of Burlington city, and Professor C. F.
Brackett of Princeton, members of the State Board of
Health, visited the Almshouse and concluded that the
disease was a threat to the entire community. To con-
tain the epidemic, they recommended a system of
quarantine and a program of disinfection to be admin- i
istered by medical personnel. However, by this late date
some of the residents had departed hastily from the
poorhouse. Camden city declared a quarantine de-
signed to prevent any intercourse with the Almshouse.
As a result of the second visit by Dr. Hunt, steps finally
were taken to properly cleanse the buildings and resi- :
dents. Dr. McCullough reported to Hunt that he had
personally “organized a scrubbing and whitewash
force.” McCullough’s optimism was well-founded, but
not for himself; he died of typhus fever on March 16,
1881. 2362023
The working people and the
needy in Camden were the
victims of the triad of sin,
poverty, and disease.
Dr. Hunt recognized that the problem was more than
a general cleanup and better sewers and water at the
Almshouse. He cited an unnamed observer who wrote,
“With regard to the disease that has been so fatal, I
think that while perhaps it did not originate in the
institution, some of the conditions were favorable to
its becoming an epidemic. Many of the men, by ex- j
posure and improper and scanty living before they
came there, were very much enfeebled, and in right
condition to take any disease. Most of them are neces-
sarily filthy in their habits. The clothes of most of these
men were saturated with filth, and were of themselves
disease-breeding. Having no knowledge of sanitary
laws, they would shut themselves up in their rooms in
the night and thus have them filled with poisoned and
poisonous atmosphere.”6
Ely April 4, the epidemic had ended. Of the 103 who
had contracted the disease, 33 died; a mortality rate
of more than 32 percent. Hunt wrote to the Freeholders
and told them that the Almshouse had been grossly
neglected. There was a general feeling that prevailed,
that events in the Almshouse were “a visitation of
Providence,” that it forewarned the county officials of
the dangers that can arise because of their neglect;
that it was necessary to conduct a continual program |
of providing the residents with clean clothes and food,
and to see to their sanitary welfare; that no expense
should be spared, and that eveiy precaution should be
taken.6
SMALLPOX IN CAMDEN
Before the events of the Asylum and Almshouse had
transpired, another epidemic had occurred in Camden
city, an outbreak that was as threatening as the typhus
epidemic and which took more lives. In February 1880,
a black worker from the Kaighnsville district painted
a home in Philadelphia in which smallpox had been
reported. He came down with the disease and a volun- fl
744
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
taiy quarantine, without legal authority, was placed on
his home; however, visitors continued to enter his
home and the disease soon spread throughout the
Seventh and Eighth Wards.24 Fear of an epidemic
prompted the dispensary physicians to urge the estab-
lishment of a hospital to isolate the victims. However,
the Sanitary Committee of the Camden City Council
argued that fumigation was sufficient to control the
outbreak. Finally, on July 26, 1880, a hospital was
established on a lot between the Seventh and Eighth
Wards, but not before a court battle had ensued be-
tween irate residents who did not want the hospital
in their district and city officials. However, the hospital
was placed on the previous site of a dump, on which
cesspool cleaners had discharged the contents of their
carts, and in the proximity of an open sewer.21724
As long as the smallpox attack was confined mainly
to the blacks and poor whites of the Seventh and
Eighth Wards, there was little concern shown by the
Icity or county officials. The manager of the dispensary
goffered to provide free vaccinations if the city donated
the vaccine; the offer was rejected. The City Medical
Society was unsuccessful in its efforts to meet with the
ientire Sanitary Committee of the Camden Council to
(establish a strict quarantine. It took the intercession
;of Dr. Hunt, at the behest of the City Medical Society,
'to arrange a meeting on July 28, 1880, between mem-
bers of the Sanitary Committee and the local phy-
sicians. His recommendations that quarantine and
(vaccination be implemented immediately were ignored
by the city officials. Only the spread of the disease
beyond the limits of the Seventh and Eight Wards
finally made vaccination more acceptable to the bu-
reaucrats. On August 16, 1880, vaccinations were
jgiven to approximately 8,000 people.21924
On November 11, a closed meeting of the city phy-
sicians was held and a reassuring statement was is-
sued that the health of the county was good and that
the smallpox no longer was epidemic.2 However, Dr.
James H. Wroth of the Camden County Dispensary
reported that there had been numerous unreported
deaths due to smallpox, and so informed the State
Board of Health.24 The following week new cases were
reported in the northern section of the city. Anxious
to lift the spectre associated with the disease, on De-
cember 15 the smallpox epidemic officially was de-
rlclared at an end by the municipal authorities.2
Two weeks later there were 8 new cases reported and
the epidemic of smallpox had reached Berlin at an
alarming rate. By July 1881, the epidemic had ended,
but not before 688 cases were reported, of which there
were 134 deaths.2 Hunt called the procrastination of
adequately protecting the people of Camden an “evil”;
that only judicious action taken at a later date helped
to lower the number of deaths.6
CONCLUSION
The working people and the needy in Camden were
the victims of the triad of sin, poverty, and disease;
victims of a system of debasement that created self-
jdoubt and uncertainty, stinkingjails, smallpox, asylum
((cruelty, almshouse neglect, and typhus fever. They
were the victims of criminal neglect because they were
poor.
A columnist in the Independent believed to be Hunt,
later wrote that the smallpox epidemic startled
Camden, “This city of contentment;” that no matter
their enterprise, their response to this disease was too
slow and that the overcrowding and unsanitary con-
dition of the paupers was the cause of the typhus epi-
demic. Disease was commonplace, poor health for large
numbers of people the norm, living conditions precari-
ous and disheartening. Fear of death was of deeper
concern to the elite than the care of the “worthy" and
“unworthy” poor, so that their first concern was to
reduce the threat to their well-being, then they
analyzed the costs and chose a course that restricted
further dangers for themselves. It was selfish and
short-sighted. Hunt, in an evangelistic tirade wrote, “I
tell you nay; but except ye repent, ye shall all perish
even thus.”25
REFERENCES
1. Snowden JW: Climatology of southern New Jersey. First
Annual Report oj the Bureau of Statistics of Labor and In-
dustries of New Jersey, 1878.
2. Camden Daily Post May 17, 1879; July 30, 1879; Sep-
tember 23, 1879; October 6, 28, 1879; November 4, 5, 7. 12,
14, 22, 1879; December 10, 24, 1879; January 6, 31, 1880;
February 6, 7, 9, 18, 1880; March 5, 17, 29, 1880; April 23,
26. 27, 1880; September 2, 3, 4, 10, 14, 1880; November 11,
12, 20, 23, 1880; December 15, 30, 1880; January 4, 8, 12,
14, 18, 22, 25, 31, 1881; February 4, 15. 16, 23, 1881; April
21, 1881.
3. West Jersey Press: November 1 3, 27, 1 878; December 1 1 ,
25, 1878; January 4, 8, 15, 1879; February 12, 19, 1879;
March 26, 1879; April 9, 16, 30, 1879; May 2h 28, 1879; June
1 1, 1879; July 2, 23, 1879; August 6, 13, 1879; September 24,
1879; November 7, 1879; December 24, 1879; January 12, 19,
26, 1881; March 2, 1881.
4. Camden Democrat: December 28, 1878; January 4, 1 1,
1879; March 22, 1879; April 5, 1879; June 14, 1879; Februaiy
5, 1881; March 19, 1881.
5. Dorwart JM, Mackey PE: Camden County New Jersey,
1616- 1976: A Narrative History. Camden County, NJ, County
Cultural & Heritage Commission, 1976; Prowell GR The His-
tory of Camden County, New Jersey. Philadelphia, PA. L.J.
Richards & Co., 1886, pp. 421-422, 423, 708; Ninth Annual
Report of the Bureau of Labor & Statistics, 1886.
6. Report of the Board of Health of the State of New Jersey:
1880, pp. 181-183; 1881, pp. 57-65, 317; 1884,'pp. 109-135;
1885, 121-129; 1877, pp. 87-101.
7. Fourth Annual Report of the Bureau of Statistics.
1881, pp. 192, 266; Seventh Annual Repod of the Bureau of
Statistics, 1884, pp. 237-256; Glassberg E: Work, wages and
cost of living: Ethnic differences and the poverty line in Phila-
delphia, 1880. Pennsylvania Histonj, XLVI, 1979; Laurie B,
Hershberg T, Alter G: Immigrants and industry: The Philadel-
phia experience. J Social His IX:2 18-248, 1975.
8. Philadelphia Times: January 8, 1881; January 9, 1881;
January 13, 1881; January 16, 1881; February 1, 1881; Febru-
ary 6, 1881; February 25, 1881.
9. First Annual Repod of the Bureau of Statistics, 1878,
p. 113; Bishop J: Suggestions for workingmen. Foudh An-
nual Repod of the Bureau of Statistics. 1881. p. 111.
10. Hunt EM: Food. Third Annual Repod of the Bureau of
Statistics, 1880, pp. 319-336.
1 1. First Annual Report of the State Chcidties Aid Associa-
tion of New Jersey to the Legislature of the State of New
Jersey. Morristown, NJ, January' 1887.
12. Boyer CS: Public utilities in Camden, NJ. Ar\nals of
Camden No. 2 (Privately printed, 1921), p. 8; and The Span
of a Century: A Chronological History of the City of Camden.
Camden, NJ, Centennial Anniversary Committee of Camden,
NJ. 1927, pp. 53, 55.
13. Wroth JH: Camden sewers. Trans Med Soc NJ, 1881,
p. 234-238.
14. Report of the 1874 Health Commission, pp. 33-34; Pub-
/OL. 81— NUMBER 9— SEPTEMBER 1984
745
lie Opinion, Vol VI, January 5, 1889, p. 259.
15. Snowden JW: Report of the District Committee. Trans
Med Soc NJ. 1881, pp. 206-207.
16. Hunt EM: The homes of the people. Report of BHNJ.
pp. 139-154, 1890.
1 7. Godfrey ELB: The medical profession of Camden Coun-
ty. Report of the celebration of the 50th anniversary of the
organization of the Camden District Medical Society, Febru-
ary 1 1, 1896. Trairs Med Soc NJ, 1896: Godfrey ELB: History
oj the Medical Profession oj Camden County, NJ. Philadel-
phia PA, The FA Davis Co., 1890.
18. Boyer CS: The Civil and Political History oj Camden
County and Camden City. Privately printed, 1922; Dinning
WM: Improvement of the local sanitary service, Board of
Health of the State of New Jersey. Second Annual Conference
oj State and Local Boards oj Health. Trenton, NJ, Mac-
Crellish & Quigley, State Printers, 1907.
19. Camden County Board of Chosen Freeholders: Minutes I
January 10, 1881, January 31, 1881; May 14. 1879; June 13,
1879; June 14, 1879: October 28, 1880‘
20. Camden County Courier: January 22, 1881; February
5, 1881; March 19, 1881.
21. Journal oj the 37th Senate of the State of New Jersey.
Being the 105th Session of the Legislature. 1881; pp.
998- i 000.
22. Special Meeting of the Board of Chosen Freeholders:
Minutes July 11, 1879.
23. Branin HE: History of "typhus Fever at Almshouse,
January 8. 1881, pp. 218, 225-226, 228-229.
24. Snowden JW: Report of District Societies. 1881, pp.
206-207.
25. State Health Boards. The Independent July 14, 1881.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
746
On Display: The Science and
Art of Healing
A museum is the caretaker of culture, the purveyor of history.
A museum captures a moment in time, halting its progress,
permitting one to savor the moment, question its signifi-
cance, and explore its ramifications. A museum exhibition provides contrast
and comparison. The viewer disembarks from the 20th century and enters
an environment laden with the trappings of another people or a different
Figure 1 — Arrow extractor with two cutting
blades made incisions around the wound to
facilitate removal of the arrowhead.
1
/OL. 81 — NUMBER 9— SEPTEMBER 1984
era History no longer is relegated to
the two-dimensional pages of the re-
cord book. History is experienced.
This is true for the three statewide
exhibits highlighting “300 Years of
Medicine in New Jersey.” These exhi-
bitions are located at the Cornelius
Low House/Middlesex County Mu-
seum, Middlesex General-University
Hospital, and the University of Medi-
cine and Dentistry-Rutgers Medical
School At these sites, visitors can ex-
perience another time— a testament to
the heritage of the people who settled
New Jersey. Exhibits include a 1906
hospital ward, a 19th century phy-
sician’s office, a 20th century dental
office and laboratory, military medi-
cine showcase, domestic and folk
medicine display, public health expo-
sition, showcase of alternative forms of
medical care, Medical Society of New
Jersey display, and wallhangings and
posters of 19th century medical rem-
edies.
The following selection of photo-
graphs by Eric Dummett captures the
essence of the celebration. Information
on exhibit hours and tours is available
from the Middlesex County Cultural
and Heritage Commission, 1-201-
745-4489.
747
Kgr, 2 1 An exhibit case displaying 19th centuiy diagnostic instruments. Exhibit: UMDNJ-Rutgers Medical School, Piscatawa.
748
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
VOL 81— NUMBER 9— SEPTEMBER 1984
749
7?2J
tes**
II
JBbmnwS
■ mfLM
Hr
W |
B Vb
1 if
^rT
is ^
is:
IgJ
1 1
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^ayiy j
Jf F ^
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3 Sel^ol P^cataway1SPlaying ' 9tH ren(uiy theraPeutics including drugs and a cupping device. Exhibit: UMDNJ-Rutgers
!
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY j
750
Figure 4— Instruments belonging to Dr. Henry Neer, a typical 19th century general practitioner. Instruments include those used
for surgery, obstetrical, and diagnostic procedures. Exhibit: UMDNJ-Rutgers Medical School, Piscataway
VOL. 81— NUMBER 9— SEPTEMBER 1984
751
A + w w ww w wwW wWWWWWW w*
loiSiSi
8821'
/ w w Sa^ W 'av' '«■*' '»■' ^a» w ^ar w ■a»» v w w w w ■»»* war w -w w ^ar w aar "w w -w w ^ ■w w -— ,.Qn
*.!i^]C^;
(t «cc (o wfii'w ftWs.; f|t*«sntfs tmtg «»<, or ttt ««8 wts< :
'JflDIB tPJJSSlilDLEiYj'
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Medical Society
mm
(•■ > Sj
|d 1
e3|i
ill
r,is
< W
O/ the Stale of
SFSW=*0 HaSIE^
SENDS GREETING:
ot five bounty
of \\atii exliiMied unto me satisfactory testimony that lie batti
studied Tiiysie and Surgery *, and \iai\i also, \\\wn examination^ the Censors of
“Tiie Bistrict .Mdeical Society for ibe County of in the
Mio
\\ State at New -Jersey f''’ gnen sufficient \»roof at Vis proficiency in tiie lie aling art.
'2 !^J and of Vis moral diameter*. as certified under tlieir bauds and seals, to me 41-
:--; » to
Yectcd as President of “Tbe Medical Society of tbe State of Xew -Jersey.
ii
rpvUO’U' V<k tinTckUkk by Virtue of tbe powers nested in me "by law , 1 do
. «- mmr* tbe
privilege of practising Tbysic and Surgery in tiiis State, together Nvitb all tiie
ex* ant unto tbe said
S 5
rights and imnumities rAiich usually appertain to Thy s icians and Surgeons.
pin xtut'tcos w&ewtfj, I \iave granted tills IViplonia, sealed ns it Vi tiie seal
of “Tiie Medical Society of tl\e State of Xcnv-
Aersey k’ and testified under my band and seal,
^ " at tl\is yttr
in,’ of /jia
^ in tiie year of our X*ord 18
) ie ;
n
President.
y*x | D. Fiti"rRandolp8 Printer, ew-BrtflnttvicI*
(jyf ' 1 VV\ ■VX'%’WAV^-V-V^XX'V'^V-V^WA/V^
Figure 5 — Diploma, issued by the Medical Society of New Jersey, signed by President Lewis Condiet, was presented to Willian
Pierson on May 9, 1820.
752
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
/OL. 81— NUMBER 9— SEPTEMBER 1984
753
Figures 7 and 8 — Display case containing surgical instruments. Of special interest on the top shelf (center) are early anesthes
containers (1885); top shelf (right) is a Lister carbolic acid sprayer. On bottom shelf (right) is a surgeon’s kit from Civil W;
days. Exhibit: UMDNJ-Rutgers Medical School, Piscataway
!
;
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY!
754
i'igure 9 — Left to right: A spring lancet and case, a 16-blade scarificator, a pair of pocket lancets and case, all used tor blood
etting; an irrigation syringe and case. Exhibit: UMDNJ-Rutgers Medical School, Piscataway
*/OL. 81— NUMBER 9— SEPTEMBER 1984
755
Figure 10— Brass microscope (ca 1880) Bausch and Lomb with case of interchangeable lenses. Exhibit: UMDNJ-Rutgers Medici
School, Piscataway
Figure 11 — Trephining set, one of the oldest surgical tools, used to bore holes in the skull. Exhibit: UMDNJ-Rutgers Medica
School, Piscataway
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY i
I
756
•Igure 12 — (left bottom) Mrs. Dinmore’s tin of cough drops, circa 1880; (left top) a drug scale; (right top) pill roller. Exhibit:
JMDNJ-Rutgers Medical School, Piscataway
VOL. 81— NUMBER 9— SEPTEMBER 1984
757
Oral
Suspension
250 mg/5 ml
500-mg Pulvules
iff
I Oral
Suspension
125 mg/5 ml
250-mg Pulvules
Keflex
cephalexin
Additional information
available to the profession
on request.
j jp DISTA
420113
Dista Products Company
Division of Eli Lilly and Company
Indianapolis, Indiana 46285
IVSfd. by Eli Lilly Industries, Inc.
Carolina, Puerto Rico 00630
758
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS !
Samuel Alexander, m.d., and the
Uniform Medical Practice Act
Stewart F. Alexander, m.d., park ridge*
Samuel Alexander, M.D. , was a unique and talented leader of the
Medical Society of New Jersey. Best known as the father of the
Uniform Medical Practice Act, his life was replete with acts and
accomplishments that added a new luster to the practice of
medicine in New Jersey.
During periods of great stress and
great need, great men have risen
from the ranks of the Medical
Society of New Jersey to advise, protect, and lead.
The 153rd President of the Medical Society of New
Jersey, Samuel Alexander, M.D., was just such a unique
and talented leader (Figure 1). Best known as the
father of the Uniform Medical Practice Act, his life was
replete with acts and accomplishments that made the
image of the Medical Society assume new luster. Trac-
ing the path of this physician sheds light and under-
standing on many of the problems and changes that
took place in the second century of the Society.
FAMILY HISTORY
Dr. Alexander’s father emigrated to the United States
before he was in his teens. Leaving his family near
Bratislava, then Austria-Hungary, now Czechoslovakia,
he worked and saved to bring his brothers, sisters, and
parents, one by one, to this country. He married an
attractive emigrant from Bukovena, north of the
Carpathian Alps, raised a family of eight children, and
rejoiced in the freedom of his new land. Samuel, born
February 22, 1888, was the oldest son in this very poor
family — poor in the material things, but rich in charac-
ter, integrity, and drive.
Samuel began working at the age of five, selling
newspapers; each penny he earned went to the lamily
for food and clothing. Throughout his life, he worked
for everything and exulted in his ability to work. There
were no scholarships or student loans, only large
measures of self-reliance. Through his growing and
developmental years, Samuel studied avidly, stretching
for knowledge, yet working a portion of every day. He
became known for his ability to read letters received
by those who could not read, and to write letters for
those who could not write. Samuel kept account books
for merchants, arranged accounting systems for some,
and job relief for others. Paralleling his work and stud-
ies, he developed a great interest in athletics and physi-
cal fitness. He ran for exercise almost a century before
it became fashionable. Devoted to baseball, Samuel
played hardball without gloves and excelled at it.
Broken fingers, of which he sustained at least four, did
not diminish or quench his love for this sport. In later
years, he would steal off to a baseball game whenever
possible; he knew all the players, their batting aver-
ages, their weak points, and their strong points.
The desire and drive to study medicine had deep
roots. Although it seemed impossible at times, by dint
of self-study, night schools, and college credits, Samuel
was admitted and graduated from the Drug Island 1 los-
pital College of Medicine in 1910 at the age ol 22.
Samuel was accepted for internship at Hackensack
Hospital and came under the magical powers of the
talented and beloved Dr. David St. John, the founder
*Dr. Stewart F. Alexander is the son of Dr. Samuel Alexander.
VOL. 81— NUMBER 9— SEPTEMBER 1984
759
of Hackensack Hospital. The young doctor rapidly
matured under the guidance of the older physician. It
was planned that Samuel would be Dr. St. John’s as-
sociate when he completed his internship and would
continue his training and career in surgeiy.
Life, however, was to take quite a different and unex-
pected turn. Dr. Heniy C. Neer, who had practiced in
Park Ridge for 50 years, became terminally ill with
cancer. Dr. Neer was a dear friend of Dr. St. John, and
had maintained a large practice and a very current
knowledge of the newer developments occurring in
medicine. Dr. Neer had developed a veiy significant
medical library, was an innovative practitioner, and
was respected far and wide by his peers. He was a pillar
of the community. Dr. St. John asked the young doctor
to go to this area and serve the people as Dr. Neer had
done. And so. Dr. Alexander went to Park Ridge, lived
with the Neer family, and assumed the practice. His
horse and buggy and winter sleigh soon gave way to
an early automobile (Figure 2). The automobile, how-
ever, often had to be supplemented by oxen to pull it
out of the mud each spring. Dr. Alexander built his
house and brought his bride to it, serenaded, as was
the custom, by all the townsfolk.
Entering into practice. Dr. Alexander associated
himself with the local medical society. The county
medical society was the only mechanism for pro-
fessional exchange and discussion, and Dr. Alexander
saw it as an opportunity to initiate continuing medical
education. (The county medical society later would
sponsor speakers and courses at which the attendance
was astonishingly high.)
Dr. Alexander had a very large obstetric practice.
Home deliveries were the accepted type of care; realiz-
ing their limitations, and lack of reserve support, he
established the first maternity home in the area— it
was eminently successful. Maternal, prenatal, and
postnatal care were placed on high priority; the results
were very gratifying.
As his professional skills were honed by experience
and self-education. Dr. Alexander reached out into re-
lated fields of maternal welfare, public health, public
welfare, and public finance. As president of the local
Board of Health he was able to monitor and lead in
establishing each innovative program in the exploding
world of new medical knowledge.
PUBLIC LIFE
It was inevitable that Dr. Alexander’s interest in pub-
lic commitment would lead him into public life. Elected
councilman and then mayor. Dr. Alexander’s ac-
complishments were legion: he paved local roads, put
in sidewalks, established and equipped a municipal
fire department, started a complete local municipal
water system, established a municipal owned and op-
erated electric light and power system, and planned for
the income of the municipal utility systems to pay the
costs of local government.
Dr. Alexander’s record of achievement came to the
attention of county and state leaders. He was invited
to run for the office of county freeholder (county super-
visor) in Bergen County; he was elected, and never was
defeated in any election. Bergen County benefited in
many ways. His self-education in finance permitted
Figure 1 — In 1945, as President of the Medical Society of Ne
Jersey.
him to set new patterns in county finance and func
tion. Bergen County became known as the most effi
cient and most economical unit in the state while blaz
ing new chapters in public service. Dr. Alexander or!
ganized a method and formula for financial support!
of the hospitals during the Depression years and saved
them from disaster. With great compassion, he devised
and put into practice a program of home care for the j
aged, which emptied the institution previously known
as the old-age home. Sensing the diminishing need foi
tuberculosis hospital beds, Dr. Alexander transformed]
the county hospital into a general hospital. With the I
assistance and support of nationally known consult-
ants, he surveyed hospital needs well into the future.!]
and initiated the hospital planning programs. Still in I
the field of his special interest in public welfare. Dr
Alexander established the county medical examiner’: j
system to replace the archaic coroner’s office.
PUBLIC FINANCIAL CONCERNS
Dr. Alexander’s political stature rose because of his
public welfare achievements and a recognition of his 1
unusual grasp and concept of public finance. Operat-
ing on the repeated premise that a public office is a i
public trust, he astonished government leaders by
what could be accomplished. During the deepest por-
tion of the Depression when tax revenues were severely
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
760
reduced. Dr. Alexander developed a system to pay pub-
ic employees with interest-bearing script.
Achievements in public finance brought Dr. Alex-
ander to the attention of state leaders and he was a
frequent consultant to the state scene: When the
George Washington Bridge was nearing completion,
-he state had no funds to construct or complete Route
4, the only New Jersey exit planned at the time. Dr.
Alexander took the position that it was inconceivable
that the bridge would be opened without adequate
?gress. He arranged for the county to secure the funds
which were loaned to the state so the first sections of
Route 4 could be completed.
Foreseeing the growing importance of the federal
government in welfare and health matters. Dr. Alex-
ander spoke out clearly in these fields and was called
to testify at congressional and senate hearings. His
activities materially influenced legislation in these
vital areas. He ardently believed that physicians, with
other talented health professionals, should participate
in government at all levels, citing that they had the
opportunity to make great contributions to the welfare
and well-being of the public. Dr. Alexander believed
that many were fully qualified to effect leadership and
that they should learn the art of transmitting theory
into practical legislation and procedure.
A MEDICAL LEADER
Medical leadership was the achievement of which he
was most proud, as it was awarded by his peers. From
his early days Dr. Alexander recognized the needs of
medicine in the exploding technological and social rev-
olutions; he also recognized the increasing health and
welfare needs of the people. Locally, Dr. Alexander was
on the Board of Health, and, as its president for almost
20 years, guided its formative years in the adoption of
progressive public health measures. Dr. Alexander or-
ganized a county health unit, and served as its presi-
dent. While serving the public health sector, he was a
staunch supporter of organized medicine and its
responsibilities in these fields. Dr. Alexander preached
to organized medicine that change was the nature of
life and human relationships and that change was
inevitable— advising never to be afraid of change and
to desist from always being opposed to change. He
believed medicine should be in the forefront with lead-
ership guiding change into its most beneficial and
most productive pathways. To legislators. Dr. Alex-
ander always cautioned and opposed promises made
that could not be fulfilled. Active in the county socitey,
he led to its incorporation and served as its president.
For years he was a delegate to the Medical Society of
New Jersey. He was dismayed at times at the reluctance
of the Society to step forwad and confront problems
that were developing directly affecting the profession
and the public. In a fateful convention in Atlantic City,
he rose to state that the old “laissez-faire” attitude was
failing, new fresh young blood must be recruited, and
vigorous progressive fearless leadership was necessary;
he offered a candidate to do this in opposition to the
recommendations of the hitherto sacrosanct nomi-
nating committee. It was an unheard of action, but it
was successful. The vibrant, talented, and productive
young Spencer T. Snedecor was elected president and
Figure 2 — Dr. Alexander, in 1911, the first year of practice.
inaugurated a new vision to the Medical Society of New
Jersey.
UNIFORM MEDICAL PRACTICE ACT
Over the years. Dr. Alexander had been concerned
with the vagaries of medical licensure and the public
conception of and the public confusion with health
care. The license to practice is not a right, but a privi-
lege granted to qualified individuals by the various
state legislatures to protect the public. Both Dr. Alex-
ander and the legislature were perplexed and aston-
ished by the nature of limited license, special privilege
legislation, and the absence of sound definitions of
medical practice. He researched and studied the field,
discussed and debated objectives, and developed the
concept that eventually was expressed as the Uniform
Medical Practice Act. This had several fundamentals:
public interest is paramount and must be protected;
everyone offering services to the public in the healing
arts must have the same or equivalent training; if an
individual has the same or equivalent training he or
she then may offer services in whatever field he or she
is qualified; and a suitable mechanism be established
in the Board of Medical Examiners to monitor and
effect the rules and regulations.
It took years to develop and prove the concept, and
years to convince the multitude of professional health
providers that this was a wise and prudent proposal.
The legislation had to be drafted line by line and was
debated at each step; it then had to be introduced to
the legislators and to the legislature, referred to com-
mittees, debated, and redebated until it finally was
passed by both chambers and signed into law by the
governor in 1939.
The Uniform Medical Practice Act produced peace
and calm in the field for more than 20 years, and was
copied and adopted by many sister states. Unfortunate-
ly, in recent years special interest pressures, loss of
alertness by responsible groups, and deterioration of
the professional image have eroded and damaged some
of the practical and protective sections of the law.
Dr. Alexander served on most of the committees of
the Medical Society of New Jersey, familiarizing
himself with its functions, responsibilities, and prorn-
/OL. 81— NUMBER 9— SEPTEMBER 1984
761
ise. He served several terms as trustee and was elected
president in 1945 to serve as its 153rd chief executive.
Dr. Alexander was concerned particularly with the re-
turning physician veteran who had to make the some-
times difficult readjustment to civilian practice. Many
of the young physician veterans had known only war-
time medical service and never had been prepared for
private civilian life. Many of the older returning phys-
ician veterans had even more profound professional
problems. Assistance, guidance, and encouragement
were needed. Special committees were established and
special provisions were made to meet and to anticipate
needs that would develop. Opportunities for refresher
courses, opportunities for reorientation, and affording
of advanced training in the specialties, financial guid-
ance, and assistance in relocation were encompassed
in his programs. The establishment of broad-based
civilian practice, the expansion of further training and
specialty qualification, and the initiation of a tremen-
dous hospital construction program laid the basis for
the delivery of the high quality and high caliber medi-
cal practice that characterized the next decades. The
principle of assistance and support given young phys-
icians was a hallmark of his life.
Dr. Alexander had a tremendous feeling and em-
pathy for the men and women who gave so much to
serve their country in time of war. As a young phy-
sician he had taken care of many Civil War veterans
and listened as they relived their experiences; they gave
him books and records of their units and he became
so well versed in the history of the Civil War that visits
to the battlefields, later in life, were profound and
meaningful. He volunteered for service in the medical
department when General Pershing led American
forces into Mexico in 1916. In World War I, he immedi-
ately volunteered but was rejected because of a
nonsymptomatic deviated septum. Not to be daunted.:
he had the septum operated upon and again presented
himself as a volunteer, only to be rejected for similar
minor but nonremedial defects. In World War II, he
served on the Medical Manpower Board, and it often
was his unhappy responsibility to decide who would
go and who would remain. Dr. Alexander felt strongk
that one could not accept the great freedoms and ben-
efits of our magnificent country without being willing
to share in its responsibilities and sacrifices, however
great, in its time of need. After his death, in his papers
were found repeated letters to the Army, pleading for
the opportunity to serve in any capacity, in any grade
in any part of the world. The answers always were
glowing in praise, but dictated that his present duties
and services precluded such action.
CONCLUSION
A devoted father and family man, Dr. Alexander de-
lighted in his son, daughter, and grandchildren. 01
great pride to him was his daughter-in-law, Lt. Colonel
Bernice Wilbur Alexander, whose interests, talents, and
achievements so closely matched his vision of the ideal.
Her brilliant war record, her professional achieve-
ments, and her social, political, and charitable leader-
ship rewarded him for his love. During his terminal
illness, she was a national figure in the campaign of
Dwight D. Eisenhower for president. He died on Sep-
tember 3, 1952, before the election, but confident that
Dwight D. Eisenhower would be president.
Many of his homilies will remain with us andji
embellish our lives. Integrity, courage, fairness, and
compassion were basic to all his concepts. He said it
is not wise for a man to accumulate great material
wealth; better is it to accumulate wisdom, under
standing, and compassion.
762
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
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VOL. 81— NUMBER 9— SEPTEMBER 1984
763
Note: If you ’re new to medical practice in N.J. . .
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JAMESS. TODD, M.D Chairman/Board of Directors, Medical Inter-Insurance Exchange of Newjersey
AS you made your decision to establish yourself
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764
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Frederick B. Kilmer: A Notable
New Jersey Pharmacist
Roy A. Bowers, ph.d., new Brunswick*
Frederick B. Kilmer was one of New Jersey ’s outstanding
pharmacists . A dedicated professional, Kilmer worked to
advance pharmacy and the role of the pharmacist in the health
carefield .
The literature abounds with the
life and works of Frederick B.
Kilmer. American Druggist calls
lim “one of the most fascinating individuals American
)harmaey has given to the world.”1 David L. Cowen in
lis history of the New Jersey Pharmaceutical Assoeia-
ion selected F.B. Kilmer as one of two outstanding
)harmacists in New Jersey history.2
EARLY LIFE AND EDUCATION
Frederick Barnett Kilmer was bom on December 1 1,
1 85 1 , in the village of Chapinville, Connecticut, the son
)f Charles Kilmer, a minister of the gospel, and Mary
^angdon Kilmer. His early education was obtained in
he public schools of Binghampton, New York, and the
Wyoming Seminary, Kingston, Pennsylvania.3
Peter A. Soderbergh suggested Fred's academic
Dackground to be a very bothersome and bewildering
ssue, which neither he nor his wife helped to clarify
)r unravel.4 For example, after 1900, Kilmer permitted
vriters and editors to describe him as “Dr.” Mrs.
Mlmer attributed a “Ds.C.” (or, correctly, “D.Se.") to her
msband in her autobiographic writings as a matter
if course. This became conventional wisdom in time,
ind regularly was assumed and perpetuated by
vriters, editors, and reporters. Another such problem
roneerns the assertion that Kilmer graduated from the
Mew York College of Pharmacy with a Ph.C. degree in
:he 1880s. Soderbergh’s considered conclusion is that
it is likely that Kilmer took courses at the New York
College of Pharmacy on and off from 1876. The College
offered night courses Monday through Saturday start-
ing in 1878, and Kilmer easily could have commuted
from Morristown, and, later, New Brunswick, to East
23rd Street in New York, over a period of years. Yet,
Kilmer’s name does not appear on the lists of the New
York College of Pharmacy graduates for the period of
1870 to 1928.
Kilmer is said to have taken “advanced courses" at
Yale, Columbia and Rutgers in chemistry. The New
York College of Pharmacy was incorporated into Col-
umbia University in 1904, and since he lived in New
Brunswick, the home of Rutgers, Kilmer could have
availed himself of the opportunity of taking courses
there. He could have travelled to New Haven, but the
official Yale directory of graduates, nongraduates, and
honorary degree recipients (1901 to 1932) does not
include his name as an enrollee. (In fairness to Kilmer,
in his profile in Who's Who, he did not mention Yale,
but he did allow his entry to say that he graduated
from the New York College of Pharmacy.) Furthermore,
in his 1901 work, The Storg of Papaw, Kilmer is de-
scribed as "Ph.C." and "B.I.Ch.," which clouds the issue
even more, since he obviously approved the pamphlet
for release and thereby encouraged people to believe
that he was a degree- holder. There is no doubt that
*Dr. Bowers is Dean Emeritus, Rutgers College of Pharmacy.
VOL. 81— NUMBER 9— SEPTEMBER 1984
765
Kilmer was awarded the honoraiy degree of Master of
Pharmacy (Ph.M.) by the Philadelphia College of Phar-
macy and Science in 1920.5
With this data, we are obliged to conclude that
Kilmer held no degrees but the Ph.M. Why he felt he
had to allow the world to assume otherwise is an in-
triguing question. A plausible explanation for this may
rest with the state of pharmacy education in the 19th
century. Prior to 1900, “drugstore experience”— of
which Kilmer had plenty by 1880— was a major re-
quirement for a diploma in most colleges of pharmacy.
Therefore, Soderbergh concludes it entirely is con-
ceivable that, in his own way, Kilmer did have the
highest level of training in his time— and that, later,
as pharmacy education developed, he merely embraced
all of the degrees he would have had if he were a 20th
century professional.
PROFESSIONAL WORK
When Kilmer came to New Jersey, he settled in Mor-
ristown and then opened a pharmacy in New Bruns-
wick at the busy intersection of George and Albany
Streets where he remained for over ten years. He sold
his pharmacy in 1889 to become director of the Scien-
tific Laboratories of Johnson & Johnson.
Kilmer’s relationship with Johnson & Johnson
lasted for 45 years; at Johnson & Johnson he had
charge of a variety of programs. The “scientific” ac-
tivities appeared to be mainly developmental: stand-
ardization of tests and formulae, development of new
processes and techniques, and use of quality control
procedures. Some experimentation took place, how-
ever, with regard to sterilization of bandages, gauzes,
and ligatures. In addition he was responsible for some
of the advertising and public relations.2
Kilmer contributed immensely to the early progress
of the Johnson & Johnson enterprise. In 1 90 1 , he put
together the Standard First Aid Manual that Ameri-
cans loved so well, and it ran through 1 1 revisions by
1932. His editorship of Johnson & Johnson’s Red
Cross Notes (1897 to 1928) and Red Cross Messenger
( 1908 to 1930), directed at the medical and pharmacy
professions, clearly elevated public awareness several
levels above where it had languished before 1900.
Fred Kilmer, the pharmacist, displayed a catholicity
of interests, a breadth of intellect, and a capacity for
work. He joined the New Jersey Pharmaceutical As-
sociation in 1878 and served as vice-president in 1884,
and 1885, president in 1886, and secretary in 1887
and 1888. During these years, and long after he
stopped practicing pharmacy, he was a regular con-
tributor to the programs of the New Jersey Pharma-
ceutical Association and by 1920 about 30 of his
papers had been published in the Proceedings.2
KILMER AS A WRITER
Kilmer published 85 articles between January 1897
and December 1933. Appearing in the American
Journal of Pharmacy, Practical Druggist American
Druggist and the Journal of the American Pharma-
ceutical Association, they covered pharmacognosy,
history of drugs, professionalism in pharmacy, educa-
tion, commercialism, practical pharmacy, and pharma-
copoeia! analysis. A large number of articles are brief
treatises on a favorite concern: dyspepsia He als<
waxed wise on medicinal plasters, surgical dressings
old-time remedies, pharmacopoeial revisions. Sain
Hildegarde, and the positive features of the Great De
pression. His first published article of any conse
quence was “Modem Surgical Dressing” in the Ameri
can Journal oj Pharmacy (January 1897), a 15-pag<
paper he read in December 1896 at the Philadelphia
College of Pharmacy at age 45.
The voluminous file on Kilmer in the American In
stitute of the History of Pharmacy revealed a stead'
flow of correspondence over three decades with Ed
ward Kremers, noted University of Wisconsin phar
macy scientist and historian, on Kilmer’s scientific
investigations, history of pharmacy, drug plants, li
braries, and views on the status of the pharmacist anc
drugstores. The night-shades were among his favorite]
drug plants. One of Kilmer’s last letters written t(
Kremers on January 19, 1932, epitomized his respec
for Kremers: “When I am in search of something,
generally fire an inquiry at you, and you are always very
kind in your returns.”
Among Kilmer’s historical pastimes were arranging
exhibits, one of which, near the end of his life in 1933
was displayed in St. Peter’s Hospital, New Brunswick
The exhibit included: x-rays depicting a coin in th<
stomach of a child; pictures showing operations o
earlier days, with crude instruments; copies of famous
woodcuts in medicine and surgery; and reproductions
of the famous paintings of “The Doctor” and “The
Country Doctor.”6
As a perennial optimist on the glorious future of his
profession, Kilmer continually reminded pharmacists ;
in his speeches and writings about pharmacy’s pro
gress and opportunities for its advancement. Among
one of these contributions was “A Message of Cheer’
to the Chicago Veteran Druggists Association in 1933
He began by skipping back to the “good old days” when
he got his first job in a drugstore by saying: “The very
first week he heard the boss tell a man that the drug
business was ’going to the dogs.’ Business was bad j
Profits were shrinking. Incompetent men were coming
into the trade. Pharmacy was on the decline. Every-
thing was gloom. I was troubled. I did not want to sail!
on a sinking ship. My first thought was to quit. Then!
I concluded to stay the week out and get my two dollars.
I stayed on, and have been in the ranks ever since.” i
Harking back to the stories of the trials and tribu-
lations which have surrounded the apothecary, the
pharmacist, and the druggist for 40 centuries, he said:
“And yet you find a drugstore on every comer, and
several in the middle of the block” Then he went on
to list the profession’s accomplishments with the!
caveat: "When we come to look things over, do we findi i
it true that in a generation or two which we havej
spanned, pharmacy— true pharmacy— has made more
progress than in all of the 40 centuries recorded in La
Wall s book Four Thousand Years of Pharmacy.7
Kilmer was a champion of both pharmacy teachers
and editors as men of outstanding influence in mould-'
ing and guiding of pharmacy. “Hand in hand with
journalism stands,” he wrote, “the College of Pharmacy
in its work of guiding youth to become pharmacists.
Interlocking with both are the associations. Each is
complementary to the other. The advancement of phar-
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
766
nacy must come from the united efforts of these agen-
cies."8 In an era when the few pharmacy graduates in
The profession often lacked the respect of drugstore
owners, Kilmer repeatedly championed the role of the
:olleges for the betterment of practitioners. In one of
his articles, "What Is Wrong with the College Gradu-
ate?" he began by quoting the head of a store employ-
ing a goodly number of pharmacists with the oft-heard:
'I wouldn't hire graduates in pharmacy, if I could help
it." Then he prophesied eloquently that these future
pharmacists of America will hereafter control associa-
tions, help to shape legislation, make plans for college
feducation, and in the generations to come will control
pharmacy.”9
Fred Kilmer was a pioneer in championing the use
rf the public media in the enhancement of the role of
the pharmacist in health care as one of the proponents
of National Pharmacy Week. The idea from which Na-
tional Pharmacy Week emerged was bom at the 1924
.annual meeting of the American Pharmaceutical As-
jsociation.10 While Robert J. Ruth of Philadelphia is
known as the “Father of Pharmacy Week,” Ruth
ihimself paid tribute to Kilmer as an early crusader for
the cause and acknowledged that Kilmer’s efforts were
jlargely instrumental in contributing a marked im-
ipetus to the Pharmacy Week movement and its world-
Iwide mission. Because of this interest, Kilmer headed
lan Advisory Committee in 1925 composed of promi-
inent men in pharmacy from every section of the coun-
try which led to its first observance in the same year.
In the following year Kilmer sparked the observance
of Pharmacy Week locally in New Jersey through an
■expansive interview carried in The Sunday Times,
|New Brunswick, on October 10, 1926. He extolled the
pharmacist in New Jersey, and farsightedly he spoke
of the opportunities for women in the profession: “A
modem development has been dubbed ‘Pharmacy in
Skirts.' It is a fine calling for women and for a great
many of them a decided success. For one thing, they
have cleaned out the dark comers and brought
sunshine, order, and artistry into the old time drug-
store. Women patrons are glad to be served by women
pharmacists and men don’t object.”
A further example of Kilmer’s devotion to the eleva-
tion of pharmacy among the public was a string of
slogans with which he is credited. “Your Druggist Is
More Than a Merchant” simply illustrated his cam-
paign for the elevation of pharmacy to a professional
status. “Try the Drugstore First” and “Ask Your Drug-
gist” indicated that professionalism and proper atten-
tion to the front of the store were not incompatible.2
Kilmer encouraged pharmacists to pursue the his-
tory of pharmacy as a hobby. In his article “History as
a Pastime,"1 1 he said that the study of history is right-
fully within the province of the pharmacist. The
philosophic aspects of history should appeal, he con-
tinued, to the scientific man, but there are other
phases of history that are more inviting as recreation:
its pursuit will bring relief and relaxation from the
vexations which fill our lives.
FAMILY LIFE
When inquiring into the life of Fred Kilmer, one can-
not ignore his family, which had a profound influence
on him. Closest to Fred was his wife, Annie Kilbum
Kilmer, a gifted speaker, an entertaining writer, and a
talented musician. From her pen came many magazine
articles and books of rare charm and musical compo-
sition for six of her son Joyce’s poems. Her home was
the meeting place of celebrities in literature, art, and
music. Possibly her most poignant feeling toward her
husband was expressed in the dedication of her book.
Whimsical Whimsies, written in 1927 containing a
wish which Providence granted:
Dedication
To one whose counsel was always asked after I had
accomplished something, the result of which I was
a little dubious, and whose sympathy never failed
me. Who, while he may not have always under-
stood, at least fully appreciated me — who has
always granted me every wish, and who, I trust, will
grant my last, that of allowing me to go before him.
These seribblings are dedicated.
My Husband
The first Kilmer home at 17 Codwise Avenue (now
Joyce Kilmer Avenue), New Brunswick, in which Joyce
Kilmer was bom (December 6, 1886) was acquired by
the state of New Jersey and dedicated as a memorial
to the life of the war hero on July 4, 1930. The most
celebrated of his family, Joyce wrote in 1913 the popu-
lar poem, “Trees.” The poem was put to music by Oscar
Rasbach in 1922 and went on to become a staple of
popular singer’s repertoires. Both the poem and the
song still are very popular. The Joyce Kilmer Post No.
25, American Legion, and the Legion Auxiliary now
occupy the house. Currently, the second floor in the
museum contains memorabilia of Joyce. Until the
death of Fred Kilmer, the family home was at 147
College Avenue, New Brunswick, amidst the Rutgers
campus, now the site of Stonier Hall, a graduate stu-
dent dormitoiy. Fred maintained a large drug garden
at his home which frequently was open to the public.
It has been said that Fred enjoyed sitting on his back
porch overlooking Neilson Athletic Field observing
Rutgers Varsity football and other contests. The front
of his home faced an open field (now the site of a
gymnasium) where the first intercollegiate football
game occurred in 1869— Rutgers versus Princeton.12
For those who came after the Kilmer family, Joyce
assured preservation of the family name among the
public and Fred in pharmacy. Among the benefactions
in his will were two endowed awards bearing his
name.13 One was for an Annual Award to the author
of the best paper submitted to the New Jersey Pharma-
ceutical Association by a graduate pharmacist. The
other is a national award administered by the Ameri-
can Pharmaceutical Association presented annually to
an undergraduate or graduate student in a school of
pharmacy for the best paper of the student's own work
in the field of pharmacognosy. Fred Kilmer left an en-
dowment to the Philadelphia College of Pharmacy and
Science (he was a trustee for ten years) to provide for
the maintenance of the Kilmer Botanical Garden
which was adjacent to the College until October 1968,
when it was moved to an experimental greenhouse.
Kilmer’s memberships in scientific societies in-
cluded chemical, pharmaceutical, biological, sanitary,
cultural, and historical groups in this country and in
VOL. 81— NUMBER 9— SEPTEMBER 1984
767
Britain, Germany, and Argentina exemplified his broad
interests. He was president of the New Brunswick
Board of Health and of the New Jersey Microscopical
Society.2
CONCLUSION
As a person, Fred Kilmer was firm in his convictions,
taciturn, conservative, preoccupied, undemonstrative,
and obsessed with his work. He was 5'8" of medium
build, blue-eyed, and blonde— then grey-haired. He was
a smoker of cigars and a pipe, a teetotaler, an avid
reader in his field, and very careless about his appear-
ance in his twilight years. He married on Christmas
Day, 1871, at age 20, and outlived his wife and his four
children— two of whom died in infancy, and one of
whom took his own life, and the youngest, Joyce, the
soldier-poet, who was killed in action in France on July
30, 1918. He bore more than his share of grief. Kilmer
died on December 28, 1934. Kilmer’s reputation for
parsimony is belied by the contents of his will, through
which he gave in excess of $10,000 to churches, hospi-
tals, and professional groups.
Fred Kilmer was eccentric, sometimes ahead and
sometimes behind the times, and often mis
understood— but he was his own man. Fred Kilmer lie;
among members of his family in Elmwood Cemetap
in New Brunswick. On his stone it says: “I have fough
a good fight, I have finished my course, I have kept the
faith.” And so he did.13
REFERENCES
1. American Druggist, May 5, 1958, p. 90.
2. Cowen DL: The New Jersey Pharmaceutical Associa
tion 1870-1970. 1970.
3. Am J Pharm: 1935, p. 84.
4. Letter to R.A Bowers, December 27, 1983.
5. Bulletin of Philadelphia College of Pharmacy and Sci
ence, June 1920, p. 4.
6. The Practical Druggist November 1933, p. 38.
7. The Practical Druggist May 1933, p. 9.
8. The Druggist Circular. June 1927, p. 3.
9. J Am Pharm Assoc 18:4, 1929.
10. Ruth RJ: The history of national pharmacy week J An
Pharm Assoc 20:696-706, 1931.
11. The Practical Druggist January 1924, p. 20.
12. McCormick RP: Rutgers: A Bicentennial History. New '■
Brunswick NJ, Rutgers University Press, 1966.
13. J Am Pharm Assoc 24:3, 1935.
I
1
768
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
William Augustus Newell, m.d., and
The Life Saving Service
Peter J. Guthorn, m.d., brielle*
Dr. William A. Newell , a Monmouth County physician, made his
greatest contribution as father of the Life Saving Service. This
Service aided passengers and crews of wrecked vessels on the
coast between Sandy Hook and Little Egg Harbor or the adjacent
Long Island shore.
William Augustus Newell (1817 to
1901), a Monmouth County
physician and political figure,
made his greatest contribution as father of the Life
i Saving Service.
William Augustus descended from New Jersey fami-
lies, but was bom in Franklin, Ohio, where his father
was temporarily employed as a civil engineer. He re-
turned to Monmouth County with his parents, where
he attended a classical school at Perrineville which had
been opened by the Rev. William Woodhull soon after
he took charge of the Presbyterian Church in 1826.
The family moved to New Brunswick, where Newell
attended schools, and graduated from Rutgers College
in 1836.
As part of a family tradition, William Augustus
elected to study medicine. He began with Dr. VanDuser
of New Brunswick, whose daughter Johanna he
eventually married. He later enrolled in the University
of Pennsylvania, graduating with a medical degree in
1839. Two of Newell’s young brothers, William Dun-
ham and Azariah D„ studied medicine and practiced
in Monmouth County.
William Augustus began practice with his uncle. Dr.
Hankinson, at Manahawkin. The small community
was on the main road north and south through the
sparsely populated pine region, closely tied to the coast
and Bamegat Bay, and its activities. The local indus-
tries were fishing, lumbering, the production of
charcoal, subsistence farming, a diminishing bog iron
production, and development of early resort activities.
Here he became acquainted with the sea and the loss
of life following winter shipwrecks. William Augustus
was appalled when 13 bodies came ashore at one time
and later reported that in 1846, 55 bodies had been
thrown on the beach at one time.
WRECKS, WRECKING, AND LIFE SAVING
A tradition of relief, aid, and assistance to ship-
wrecked sailors had been established in England, and
in New England by the Massachusetts Humane Society
in 1786. The Humane Society established houses of
refuge along the exposed and unprotected portions of
the New England coast. These provided shelter from
the weather, food, and necessary supplies for survival
for those fortunate enough to have reached land. The
Society began to place lifeboats on the most perilous
parts of the coast about 1807. The first was at
Cohasset, close to the southern extremity of Boston
Harbor, an area of great potential danger.
The importance of wrecks and “wrecking," the
salvage of ships and cargoes, and, by extension, the
saving of lives, was recognized in colonial New Jersey.
Certain parliamentary acts for the preservation of
ships and goods forced on shore or stranded were to
*Dr. Guthorn was the first president of the Medical History
Society of New Jersey.
VOL. 81— NUMBER 9— SEPTEMBER 1984
769
be read publicly in the counties of Monmouth, Burl-
ington, Gloucester, Salem, Cumberland, and Cape May
at four succeeding courts of General Quarter Sessions.
Passed June 28, 1766, they decreed the death penalty
for those willfully attempting to bum or destroy a ship.
Other legislation in 1825, and later years, was con-
cerned with the organization and local administration
of wreck management and salvage.
The shore area was divided into districts, each under
a “wreckmaster.” These were local residents of
substance and good reputation, commonly retired
shipmasters or surfmen, who were responsible for sav-
ing wrecked passengers and crew, and for retrieving
salvageable cargo, gear, and rigging. They were ap-
pointed for terms by the courts, and were under bond.
Occasionally, an intact stranded vessel could be
salvaged; but that rarely occurred before the advent of
iron or steel hulls.
A distinctive type of small boat was developed along
the shore for wrecking and life saving. Their model was
that of the smaller beach skiffs used for fishing. The
“surf boat” and beach skiff were designed for
launching through the surf, to survive off shore, and
to land through the surf. Both were constructed by the
same boat builders and manned by the same surfmen
or fishermen, depending upon the needs of the mo-
ment.
The boats were constructed of light lap strake cedar
planking over steam-bent white oak frames. The boats
had a lively sheer, an essentially semicircular mid-
section, and a sharply raked, “U”-shaped transom.
They were buoyant, light in weight, and handy. The
fishing version was about 15 feet in length and 5 feet
in beam, launched and rowed or sailed by two men. The
surf boat version was about 25 feet in length and
comparatively narrower in beam, 6 to 7 feet. It was
rowed by four or five oarsmen and steered by the cap-
tain in the stem, using another long oar. Great care
was taken in the construction of the boats and selec-
tion of the crew, particularly the captain (Figure 1).
The operation of surf boats often was a joint
enterprise. An “Article of Agreement of a Surf Boat,”
dated April 13, 1835, is preserved in the Monmouth
County Historical Association. The owners, John S.
Forman, Morris Freeman, John Morris, and William
Akins, agreed to build and own a large surf boat for
the purpose of working at wrecks. The document notes
that in addition to sharing the ownership, they are “to
agree in the selecting of the man to go in the stem of
said boat or be captain." Forman was a Manasquan
lawyer; Freeman, a boat builder; and Akins, a retired
shipmaster and surfman.
Some additional light is shed in an 1846 report by
a legislative commission. Three legislators, Peter
Vredenburgh, John S. Darcy, and Jonathan C.
TenEyck, were appointed by the governor to in-
vestigate charges against inhabitants of the coast of
Monmouth County, at the time extending from Sandy
Hook to Little Egg Harbor Inlet. The charges, refusal
to give relief to perishing passengers and crewmen,
plundering the dead, and extracting money for the
delivery of bodies, arose following the wreck of the ship,
the John Minturn. The charges were made by members
of the crew to the American Shipwreck Society of New
York. They were taken up by the press, particularly in
Figure 1 — An artist’s rendenng of surf boat launching. An
1887 chromolithograph by Frederic S. Cozzens (1846 to
1928). A technically correct study of the boat and crew
launching through the surf to render aid to the crew of a(
stranded vessel, dimly seen at the left, off shore.
New York, and magnified to include wholesale charges
of land piracy and even murder.
The report consists of the sworn (in the case of the
Quakers, affirmed) depositions of local inhabitants,
the coroner’s memorandum book, and correspon-
dence. It disproves the serious charges and indicates I
the guilt of some of the crew of the Minturn. It gives
much valuable data, including the use of the term “surf
boat,” and imparts a great aura of respect for the words
and judgments of the wreckmasters and surfmen. The '
general impression of the statements of the 40-odd 1
deponents in the report is that of personal hardihood,
and an ability to come to terms with the hostile en-
vironment and its effect.
PRACTICE AND FIRST POLITICAL LIFE
Dr. Newell established his own practice in Im-
laystown in 1841, and won his first political office, that
of township collector. He was re-elected many times
until he moved the short distance to the larger Allen-
town, a center of activity and transportation in western
Monmouth County. Here his practice prospered in the
busy community. Well known and popular. Dr. Newell
declined a nomination to fill an unexpired term in
Congress in 1845, but was elected in 1846; and re-
elected by an increased majority in 1848. Abraham
Lincoln, a member of the same Congress, occupied an
adjoining seat in the House. They boarded and roomed
together, becoming close friends.
NEWELL AND THE LIFE SAVING SERVICE
In an address to the Congress in 1848, Dr. Newell
reported that the New Jersey coast between Sandy
Hook and Little Egg Harbor was more famous for ship-
wrecks than any other part of the country, including
the Florida Reef, as the Keys then were known. In a
little more than nine years preceding July 31, 1848,
1 58 vessels had been wrecked on the New Jersey coast
including ships, brigs, schooners, sloops, and pilot
boats; and 180 vessels had been wrecked on the adja-
cent Long Island coast. These statistics had been
gathered by Dr. Newell from some of his constituents,
some of whom had been deponents in the 1846 legis-
lative report. The adjacent New Jersey and Long Island
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
770
Figure 2 — Among the wreckers of the New Jersey Coast, this
woodcut illustration was drawn by Granville Perkins (1830
to 1895), from Harper's Weekly of January 25, 1868. A
spirited conjectural series of views of the activities of the
wreckers in rescuing stricken passengers and crew members.
Pictured are a "Government Working House," wreckers' hut,
the recovery of cases of flotsam containing bottles of joyful
wreckers, recovery of the drowned, and finally, "the strangers'
grave."
chores were the sides of a hazardous funnel directed
to the entrance of New York Harbor, at peril in great
storms and in decreased visibility, in the days before
steam replaced sail. There was no national agency or
regular register of shipwrecks or marine disasters or
organized service of rescue.
Dr. Newell pointed out that the shore was made es-
pecially dangerous by sand bars from 300 to 800 yards
offshore, which could be covered by relatively few feet
of water. A stranded vessel's crew and passengers were
separated from the safety of the shore by an im-
passable surf, while the vessel was breaking up be-
neath them. The ordinary ship's longboat was not able
to pass over the bar, or negotiate the surf while a surf
boat could, and would survive in a sea and come to
shore when the other would be swamped or stove.
The important part of the address was an amend-
ment to the Light House Bill for $10,000 to provide
surf boats, rockets, carronades, and other necessary
apparatus for the better protection of life and property
from shipwrecks on the coast of New Jersey, between
Sandy Hook and Little Egg Harbor. The amendment
was adapted unanimously, and established the Life
Saving Service (Figure 2).
LATER PRACTICE, POLITICS, AND
GOVERNORSHIP
Dr. Newell was an earnest opponent to the extension
of human slavery during his two terms in Congress
from 1847 to 1851. He resumed practice in Allentown,
continuing an interest in politics, local fraternal or-
ganizations, farming, and the Presbyterian Church.
Nominated for governor in 1856 by a convention of
representatives of the new Republican party, and the
American party, a residual of the old Whig party, Dr.
Newell was elected, and served two tenns from 1857
to 1861. President Lincoln appointed him super-
intendent of the Life Saving Service in New Jersey in
1861, and he served until 1864.
Dr. Newell received the Republican nomination for
Congress a third time in 1864, was elected, and aided
Figure 3— An 1880 (circa) photo of Life Saving Station
Number 5 at Green's Pond near Long Branch, now named
Lake Takanasee. The station was long associated with the
Captains Green, who served as wreckmasters, fomied volun-
teer crews, and were captains of later life-saving crews. The
surf boat pictured, Ella Green , probably was built by William
Seaman at Branchport. Other equipment pictured includes
a life car in the foreground, invented by Captain Douglas
Ottinger of the Revenue Service, and later claimed by Joseph
Francis. It was used as a rescue vehicle in place of the
breeches buoy in high surf. Also shown are the Lyle gun,
projectiles, storm lamp, line sulky, mid other necessary gear.
The captain mid six oarsmen in the foreground are wearing
cork buoyed life jackets. Two reserves are on lookout. The
original building still is standing.
further in the development of the Life Saving Service
(Figure 3). His old friendship with President Lincoln
was renewed, and he served as attending physician at
the White House.
Dr. Newell ran unsuccessfully for Congress in 1866
and 1870. A factor was the ascendancy of the Demo-
cratic party, and hostility of many disappointed Re-
publican applicants for office who were critical of his
honest dispensing of party patronage in the past. The
same factors defeated his 1877 candidacy of governor.
He resumed practice in Allentown in 1867, until ap-
pointed governor of the Washington Territory by Presi-
dent Hayes in 1880. He also was appointed Indian
inspector in the same territory, practiced medicine for
a year in Olympia, and was resident surgeon in a vet-
erans’ home there.
FINAL YEARS AND A PERSPECTIVE
Advancing years and the death of his wife prompted
Dr. Newell’s return to Allentown in 1899. He resumed
practice in response to local demand and personal
popularity. As an elder and respected statesman, he
was invited to address the Monmouth County Histori-
cal Association in 1899, and again the following year
on the topic of the Life Saving Service.
Among his interests was the improvement of agricul-
ture. Dr. Newell was president of the New Jersey State
Board of Agriculture in 1875, and his efforts were im-
portant in support of a federal bureau of agriculture.
Political activities and personality, and many social
activities led to membership and office in many or-
ganizations. He was vice-president of the National
Union League for many years. (The Union League had
formed in the North after disastrous Union Army de-
feats during the early years of the Civil War. Clubs in
VOL. 81— NUMBER 9— SEPTEMBER 1984
771
many cities distributed war literature, recruited white
and black volunteers for the anny, and raised money
for soldier’s relief. Union League clubs in Chicago,
Philadelphia and New York trace their origin to this
movement.)
Dr. Newell was also a Freemason, and member of the
Odd Fellows, and a trustee of Rutgers College. Two of
his seemingly minor activities had other far-reaching
effects. He was a delegate to the Republican convention
in Chicago in 1860 which nominated Abraham Lin-
coln. He was later foreman of the Monmouth County
Grand Jury which prevented the reopening of the Long
Branch gaming and gambling houses and of the race
track.
William Augustus Newell continued to remain active
until his death in Allentown on August 6, 1901,
survived by his three children. He was eulogized by a
large number of previous supporters and opponents;
and buried with honors in the Allentown Presbyteriaj
churchyard.
REFERENCES
1 . Allinson S: Acts Of the General Assembly of the Provinc!
Of New Jersey. Burlington, NJ, 1776.
2. Elmer LQC: A Digest of the Law of New Jersey, Fourt ,
Ed. Newark, NJ, 1868.
3. Gordon TF: A Gazetteer Of The State oj New Jersev
Trenton, NJ, 1834.
4. Gut horn PJ: The Sea Bright Skiff and Other Jerse
Shore Boats. New Brunswick, NJ, 1971.
5. Nelson W: The New Jersey Coast In Three Centurie: j
New York, NY, 1902.
6. Newell WA Remarks to the Monmouth County Histories
Association, 1899.
7. Newell WA Remarks to the Monmouth County 1 listorica
Association on the Life Saving Service, 1900.
8. Report of the Commissioners To Investigate the Charge:
Concerning the Wrecks on the Monmouth Coast, corn!
municated to the Assembly, March 20, 1846, Trenton, NJ
1846.
772
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Women Physicians of New Jersey:
The Early Era
Christine E. Haycock, m.d., Newark*
Representative women physicians have been selected to try to
symbolize the roles of women in the medical history of New
Jersey . These outstanding doctors have added tremendously
to the health care of New Jersey.
At the turn of the century, there
were about 300 women doctors
in New Jersey.1 In 1950, there
were 425 women physicians; in 1960, 669; in 1973,
1,052; and in 1983, over 2,000. In 1905, 4.1 percent
of all medical students were women; in 1910, 2.6 per-
cent; in 1950, 5.9 percent; in 1961, 5.8 percent; in
1965, 7.3 percent; and in 1975, 20.4 percent. The cur-
rent percentage is about 32.46
Statistics indicate that there were 19 medical col-
leges for women between 1850 and 1895. This number
dropped to 8 by 1900 and to 2 by 1910 (in New York
City and in Philadelphia) as women began to be ac-
cepted in many formerly all-male schools.2 The famous
Flexner report published in 1910 was supportive of
coeducational medical schools and probably aided this
metamorphosis.3
In general, women were more apt to be found in
family practice, pediatrics, and psychiatry. In the early
1960s, women physicians in surgical specialties rep-
resented less than 2 percent of all physicians. Although
women had practiced surgery in New Jersey, it was not
until 1961 that Dr. Anita Falla and the author became
the first board certified general surgical specialists in
the state.
The American Medical Association (AMA) did not
accept women as members until 1915, and even then
the opportunity to have a paper accepted for presen-
tation was nearly zero. As a result, a number of
women’s medical associations formed around the
country and a medical women’s journal was founded.
This resulted in the American Medical Women’s As-
sociation (AMWA) organized by Bertha Van Hoosen of
Chicago, coming into existence that same year as a
national organization.7
New Jersey medical women did not form their own
organization until June 1924. Dr. Clara De Hart Krans,
of Plainfield, conceived the idea of “promoting friend-
ship” among women physicians and so the New Jersey
Medical Women’s Association (NJMWA) was born; in
1927, it became a branch of the AMWA8 Many promi-
nent New Jersey women physicians have been mem-
bers of the NJMWA and honored as "Woman of the
Year.” The group acts to secure positions for phy-
sicians and help the American Women’s Hospital As-
sociation in its overseas work. The group also was
active in seeking passage of the HR 826 Bill in Con-
gress in 1943 sponsored by Congressman Emanuel
Celler of New Jersey which allowed qualified women to
receive commissions in the Armed Forces. Shortly alter
its passage, four New Jersey women physicians were
commissioned and served in World War II. Later, New
Jersey women served overseas in the Korean and Viet-
nam Wars.9
It would be impossible to present a study of every
*Dr. Haycock is Associate Professor of Surgery, UMDNJ New
Jersey Medical School, Newark.
VOL. 81— NUMBER 9 — SEPTEMBER 1984
773
early woman physician. Representative women have
been chosen to try to symbolize their roles in the medi-
cal histoiy of New Jersey from 1834 to the 1960s.
Sophia Presley, M.D. Bom in Ireland in 1834, Dr.
Presley came to the United States as a child. She stud-
ied premed at Granville Female Seminaiy, Ohio, and
attended Women’s Medical College of Pennsylvania,
graduating in 1876. Since no other hospital would
accept her, Dr. Presley interned at the Women’s Hospi-
tal of Philadelphia and remained there an additional
three years as an instructor in surgeiy. Dr. Presley
then set up a general practice in Camden in 1881 while
remaining a clinical instructor at the Women’s Medical
School. For seven years she struggled to gain member-
ship in the Camden County Medical Society, finally
succeeding in 1896. During her early years of practice
she was forced to move at least nine times from one
office apartment to another until 1907 because “repu-
table ladies ostracized the early medical women of
America and landlords refused to rent them apart-
ments for offices.” According to her biographer, Cleora
Teffean, Dr. Presley had a large practice at her death
in 1909 at age 75 as recorded in the Journal of the
Camden County Medical Society.10 She was ac-
credited with “earnest zeal and ability” in gaining pa-
tient confidence especially of many prominent families.
Dr. Presley authored a number of papers on various
topics: acquired syphilis, rectal polyps, and puerperal
fever. In 1894 to 1895 she was elected secretary of the
Camden County Medical Society. In 1894, she headed
the gynecological department of the Camden City Dis-
pensary.
Mary E. Gaston, M.D. Bom in Somerville in 1856,
Dr. Gaston attended Vassar College and graduated
from the Women’s Medical College in 1883. She ob-
tained an internship in Boston and returned to
Somerville in 1884 to begin a general practice. Her
obituary noted that she used a horse and buggy to
make rounds in the early days of her practice but gave
that up in favor of walking. Her father gave her a gun
to carry to protect herself, but Dr. Gaston said she was
more afraid of the gun than of any harm that might
come to her and left the weapon home after a few days.
Dr. Gaston retired from practice in 1908 and then
devoted her time to establishing the Somerville Civic
League, a Red Cross Chapter, the Somerset County
Health and Tuberculosis Association, and Somerset
Hospital. She died at 100 years of age in 1956.
Alicia H. Ward, M.D., and Emma Edward, M.D. The
sisters were bom around 1855. Data available do not
indicate their medical school, but they practiced in
Newark in an office which now is the site of the Newark
Public Library. Dr. Ward continued to practice until
1922, her sister having passed away several years
earlier. She died in 1935.
Florence Voorhees, M.D. Bom around 1870 in
Woodbridge, Dr. Voorhees graduated from the
Women’s Homeopathic Medical College in New York
and then studied in Europe as did many women to
become specialists. After returning from Europe she
opened an office in Newark with Dr. Maiy Broadnax
and practiced obstetrics and gynecology; she was on
the staffs of Presbyterian, Saint Barnabas, and East
Orange General Hospitals.
Ellen Potter, M.D. One of the most prominent early
women physicians in New Jersey, Dr. Potter was bom
in 1871 in New London, Connecticut. She obtained her
medical degree from Women’s Medical College in 1903
at the age of 32. Dr. Potter went to New York City to
study art; but while living in a settlement house she
noticed the need for medical care for the poor and
decided to make medicine her career. After graduation
she entered general practice for 15 years. She became
medical director of Women’s Hospital from 1918 to
1920. In 1921, she helped found the Bureau of Chil-
dren of the Pennsylvania Welfare Department and
headed that agency until 1923. Then she became sec- I
retary of welfare in Pennsylvania until 1927, the first
woman to hold a state cabinet post. Dr. Potter joined
the staff of the New Jersey Department of Institutions
and Agencies and served successively as organizer and
director of the medical department of North Jersey
Training School for Feeble-Minded Females, Totowa
and then superintendent of Clinton Reformatory for
Women and the State Home for Girls, Trenton. In 1930,
she became director of medicine in the department
until 1946 when she was promoted to deputy com-
missioner in charge of welfare and assistance. In the
depression of 1933, Dr. Potter worked for the Federal
Relief Administration, directing the care of transient
unemployed throughout the countiy. During World
War II, she chaired the child welfare committee of the
State Office of Civilian Defense. In 1941, she became
president of Women’s Medical College serving until
1943 while still with the New Jersey Department of j
Institutions and Agencies. One of Dr. Potter’s main
accomplishments was in the formulation by the state
of regulations governing adoptions in 1946. She
fought to prevent a “black market” in babies and
provided protection for both the natural parents and
the adoptive parents. After her retirement in 1952, she
continued to do volunteer work for various state agen-
cies and commissions. She served as national presi-
dent of the American Medical Women’s Association in
1929 and was honored as the “Woman of the Year” by
the New Jersey Medical Women's Association in 1954.
Dr. Potter was beloved by her colleagues and friends
for her calm demeanor and friendly laugh. She enjoyed
challenges and her main concern was for the care of
the needy. She died in 1958.
Stella Bradford, M.D. Bom in 1871 in Montclair, Dr.
Bradford graduated from Smith College in 1889 and
traveled in Europe where she studied in Denmark, !
Italy, and Germany specializing in sociology. From
1895 to 1896, she taught elementary school in Eliza-
beth and was an assistant professor of English litera- j
ture at Smith College. Dr. Bradford then entered Cor-
nell University Medical College and graduated in 1902.
After interning at Worcester Memorial Hospital in
Massachusetts she returned to Montclair. In 1903, Dr.
Bradford opened a private practice which lasted 52
years. She became a clinical assistant at Gouvemeur
Hospital, New York, and founded a tuberculosis clinic
there in 1905. Dr. Bradford became interested in
physical medicine and in 1932 was appointed director
of that department at The Mountainside Hospital until
her retirement in 1936. In 1950, she was called back
from retirement to head the department and stayed
until 1953. During her career she worked with handi-
774
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
rapped children and adult patients with severe
irthritis. Dr. Bradford established the first visiting
uirse service in Montclair and the first fresh air school
ind tuberculosis clinic. In addition, she authored
nany papers in her field of rehabilitation medicine
ind was active in many professional societies. Dr.
Bradford never married and died in 1959 at the age
bf 88.
Frances Bartlett Tyson, M.D. A descendent of Dr.
Josiah Bartlett, a signer of the Declaration of Indepen-
dence, Dr. Tyson was bom in 1874 in Vineland. At 17,
she tried to enroll in a nursing school but was told she
was too young. She took a job in the pharmacy of
Philadelphia's Women’s Hospital and later graduated
rom The Philadelphia School of Pharmacy in 1896.
Working as a pharmacist enabled her to earn enough
noney to complete a two-year premedical course at
Temple University and to earn her medical degree from
Women’s Medical College in 1901. She practiced until
(1909 when she married William Tyson, an insurance
(nan, who persuaded her to quit practice; they had a
daughter in 1910. In 1918, with World War I creating
a physician shortage. Dr. Tyson tried to convince her
husband she was needed in Leonia since all four local
physicians were in the army. Yet it took the inter-
vention of the town council to convince him: on his
pommuter train every day they complained how badly
a doctor was needed. He ended up urging his wife to
iretum to practice. During the influenza epidemic of
ithat year. Dr. Tyson served the town practically single
handedly, organizing women’s clubs to help carry out
feeding schedules for families with multiple victims.
She herself fell prey to the disease and lost the hearing
in her right ear. Dr. Tyson remained in practice, mak-
ing houseealls in all kinds of weather. She solved the
problem of climbing Leonia’s icy hills by wearing her
husband’s galoshes fitted out with metal cleats. Her
husband died of leukemia in 1948 after a long illness
jand she became the supporter of her family. In 1918,
Dr. Tyson was appointed school physician and health
officer for the town. She remained in this post long
after her retirement from active practice — the school
board simply refusing to accept her resignation at the
age of 77. At the age of 83, Dr. Tyson was honored by
the New Jersey Medical Women’s Association as
‘Woman of the Year” in 1957. Greatly beloved by her
colleagues and patients. Dr. Tyson remained active in
volunteer work in her community until her death.
Marie Louise Lefort, M.D. Bom in Newark in 1875,
Dr. Lefort graduated from the New York Infirmary for
Women and Children in 1898. In 1899, she was ap-
pointed district physician for the Old Newark Board
of Health and served the city until 1918 when she
volunteered to go to France to establish a hospital for
gassed soldiers. Dr. Lefort remained in France at
Rheims’s American Memorial Hospital for 21 years and
was awarded the French Legion of Honor for her work.
She returned to New Jersey in 1939 to retire; and at
the age of 82, Dr. Lefort died here in 1957.
Sara D. Smalley, M.D. A native of Newark, Dr.
Smalley graduated from New York Medical College and
Hospital in 1900. She established a general practice in
Newark in 1901 and remained in practice until her
death in 1952. Dr. Smalley was active with the Newark
Equal Suffrage League and was a charter member of
Zonta International, a noted women’s professional or-
ganization, which also included Amelia Earhart as a
founding member.
Vera Schectman, M.D. Bom in Odessa, Russia, in
1884, Dr. Schectman came to the United States in
1906. She graduated from Women’s Medical College in
1912 and came to Newark to practice. In 1926, she
became the first woman physician on the staff of New-
ark Beth Israel Hospital and outraged some of her
friends and colleagues in 1916 by giving lectures on
sex education. Dr. Schectman was married and retired
only a few years before her death.
Louise Pearce S kilim an, M.D. Bom in 1885, Dr.
Skillman lived in New Jersey for 38 years. At one point
she led an expedition through the jungles of
Leopoldville, Africa; in 1915, she helped develop a drug,
tiyparsamide, used to treat African sleeping sickness.
She was president of the AMWA in 1946. She died in
1950 at age 65.
Ella Coughlan, M.D. Bom in 1886 in Hastings, On-
tario, Canada, Dr. Coughlan had to fight her father’s
disapproval to enter medical school. As a result she
began her career as a nurse, a common circumstance
for many women physicians. When her father died and
left her an inheritance, Dr. Coughlan immediately took
premedical courses at the University of Toronto and
entered Women’s Medical College; she graduated in
1914. After interning in Women’s Hospital she came
to Orange as school physician where she served for 42
years. When the Salk vaccine against polio became
available she almost single handedly saw to it that over
2,000 students received an injection. Additionally, she
had a private practice in gynecology until 1948. She
retired from medicine in 1951 and died some years
later.
Linda Bauer Hauck, M.D. Bom in Newark, Dr.
Hauck graduated from Women’s Medical College in
1914. In 1918, she joined the Public Health Service as
a first lieutenant until World War I concluded. During
this period she married and moved to Irvington where
she practiced for over 40 years. Although forced to
discontinue practice in 1943 because of poor health.
Dr. Hauck collected clothing and food to send abroad
to Holland, England, and France at her own expense.
She was cited by the mayor of Walshein, Holland, for
her aid to the distressed. Much beloved by her col-
leagues because of a gentle good humor and concern
for young women entering medicine. Dr. Hauck was
honored in 1957 as “Woman of the Year" by the New
Jersey Medical Women's Association. Dr. Hauck died
in 1964 at the age of 77, and both her son and daugh-
ter followed in her footsteps as physicians.
Rita S. Finkler, M.D. Perhaps one of the most dis-
tinguished women physicians in New Jersey, Dr.
Finkler of Short Hills was bom in Russia in 1888 to
peasant parents. She began studying law at St.
Petersburg University and shortly was thrown into
prison for attendance at student anarchistic meetings.
As soon as she was released from prison, Dr. Finkler
came to the United States to continue her studies and
changed her career to medicine. Graduating from
Women’s Medical College near the top of her class In
1915, Dr. Finkler made headlines by becoming the first
woman intern at Polyclinic after placing in a com-
petitive examination at Philadelphia General Hospital.
VOL. 81— NUMBER 9— SEPTEMBER 1984
775
Dr Finkler made the news when she rode the horse-
drawn ambulance around Philadelphia with "poor old
Jerry" pulling the vehicle; this amusing story of an
ailing horse pointed out the need for a motor am-
bulance. Dr. Finkler, who spoke eight languages, spent
the next several years studying abroad concentrating
on endocrinology. Also, she practiced in Newark, writ-
ing over 70 papers in the field of endocrinology after
establishing and heading the first such department of
medicine in New Jersey at Newark Beth Israel Hospital.
Although retired from practice after 55 years. Dr.
Finkler continued to travel and lecture throughout the
world until her death in 1968. She was honored as
"Woman of the Year” by the NJMWA in 1956 for her
work in 1947 as national chairwoman of the Emerg-
ency Committee of the AMWA which sent over 6,000
pounds of clothing, food, vitamins, and medical instru-
ments to Europe to aid their colleagues.
Elizabeth Brackett, M.D. Bom in New York City in
1892, Dr. Brackett was raised in Ridgewood, until 1912
when she entered nurse's training in New York. After
graduation in 1915, she became an army nurse and
served in France with an American unit attached to
the British Expeditionary Force. It was in France that
she decided to try to become a physician. After return-
ing from France, she entered Columbia University,
graduating in 1929 from the College of Physicians and
Surgeons. After interning at Newark City Hospital and
taking residency training in pediatrics at Children’s
Hospital, Philadelphia, and in Newark, Dr. Brackett set
up a practice in Nutley over a comer dmgstore. Find-
ing that she could not support herself by just doing
pediatrics, she became a general practitioner and sur-
geon with privileges at many area hospitals. In 1962,
Dr. Brackett was honored by the NJMWA as “Woman
of the Year” because of 30 years of outstanding sense
of community welfare, never stinting of her time to her
patients; never refusing a housecall until age and
health forced her to do so. She actively supported the
visiting nurse service of Nutley. Dr. Brackett was presi-
dent of the NJMWA and was national treasurer of
AMWA 111 health forced her retirement in the 1960s,
and she died in 1974.
Mildred Gregory, M.D. Bom in 1884, Dr. Gregory
was raised in Newark. She earned an undergraduate
degree from Wellesley in 1916 and a master’s degree
in biology from Columbia, and taught at Skidmore
College in Saratoga until 1924. Then she entered Col-
umbia College of Physicians and Surgeons, graduating
in 1928. After interning at Newark City Hospital, Dr.
Gregory completed a residency in pediatrics at St.
Mary’s and Babies Hospital, Newark. In additon to
practicing pediatrics in Newark from 1955, Dr. Gregory
became medical director of Babies Hospital from 1949
to 1957 and was one of the first women diplomates of
the American Board of Pediatrics. She was very active
with the YM-YWCA of Newark and the Advisory Com-
mittee of the Essex County Clinic for Retarded Chil-
dren. A quiet, unassuming woman, beloved by her pa-
tients and with outstanding professional ability, Dr.
Gregory was named “Woman of the Year” by the
NJMWA in 1961. She retired a few years later and died
in 1975.
Jeannette Munro, M.D. Bom in 1894, Dr. Munro
was Princeton’s first woman pediatrician and prac-
ticed there from 1933 to 1965. She was honored as
“Woman of the Year” by the NJWMA in 1965. She
recalls the era of S3 housecalls and $2 office visits or
a dozen eggs. Dr. Munro originally had planned a ca-
reer in social work but changed to medicine and
graduated from the University of Wisconsin in 1927.
She found herself resented as a “specialist” when she
first opened her pediatric practice, but she soon won
over her colleagues in Princeton by her dedication and
professionalism.
E. Mae McCarroll, M.D. Described as the “first lady
of the National Medical Association," Dr. McCarroll wasl
born in Birmingham, Alabama, in 1898. Graduating as
one of the first black women physicians from Women’s-
Medical College in 1925, Dr. McCarroll interned at
Kansas City General Hospital and after marriage in
1929 moved to Newark where she practiced for over
48 years. She was active in many civic and community
affairs and led a Newark crusade in the early 1930s
to stamp out venereal disease. In 1934, Dr. McCarroll
was appointed a clinic physician in the venereal dis-
ease division of the Newark Department of Health. She
did public health postgraduate study at Harvard. In
1946, Dr. McCarroll became the first black physician
to be appointed to the staff of Newark City Hospital and
she was named deputy health officer of the city. Dr.
McCarroll was active for over 16 years with the Na-
tional Medical Association and helped establish its
journal as a tme professional publication. She was
honored in 1973 as that organization’s “first lady.” She
currently is retired.
Anne Lardner Moore Shannon, M.D. Bom in
Pineville, North Carolina in 1898, Dr. Shannon gradu-
ated from Cornell University Medical College in 1924.
She did her postgraduate work in Europe and Man-j
hattan General Hospital; and completed a residency at!
Bellevue in otolaryngology. Dr. Shannon became the j
first woman physician on the staffs of The Moun-j
tainside and Montclair Hospitals and the only woman
surgeon. Dr. Shannon was a Diplomate of the Ameri-
can Board of Otolaryngology and a Fellow of the Ameri-
can College of Surgeons. Dr. Shannon died in 1960j
after a long illness.
Carye-Belle Henle, M.D. Bom in 1899, Dr. Henle
received her medical degree from Columbia University
College of Physicians and Surgeons. She became the j
first woman resident in radiology at Mount Sinai Hos-
pital, New York City, where she met and married her
husband. Dr. Harold Connamacher. In 1929, Dr. Henle
purchased x-ray equipment and joined her husband
in practice in Newark as New Jersey’s first woman j
radiologist. In 1956, she was recognized by her col-
leagues by her election as the first woman president
of the Radiological Society of New Jersey. For many
years she was deeply engrossed in the long-range
Radium Research Project of the New Jersey State De-
partment of Health, seeking to determine the long- 1
term effects of exposure to radioactive material. The
subjects were radium dial painters of 1910 to 1920 in
northern New Jersey. Dr. Henle was honored as
“Woman of the Year” in 1963 by the NJMWA. She
retired in the late 1960s and died in 1977.
Eva Brodkin, M.D. Bom in Brooklyn, New York, in
1899, Dr. Brodkin was encouraged to become a phy-
sician by her father. Dr. Isador Topkins. She graduated
776
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
from Women’s Medical College in 1924 and became the
first woman intern at Muhlenberg Hospital, Plainfield.
When Dr. Brodkin began her internship she was told
she was an “experiment.” She resolved never to take
advantage of being a woman, but did everything asked
of her including riding the ambulance and hauling
stretchers. After entering general practice in 1925, she
met and married Dr. Henry Brodkin, a thoracic sur-
geon. After her third child, she and her husband de-
cided that a specialty would be better for her than
general practice. For three years, six times a week, she
took instructions in dermatology in New York; in 1931
she became New Jersey’s first woman dermatologist.
Dr. Brodkin was honored for her excellence in her
specialty by her colleagues of the New Jersey
Dermatological Society who elected her president in
1952. Dr. Brodkin was chief of the dermatology service
at Saint Barnabas Hospital for many years. Her son,
Dr. Roger Brodkin, currently is professor of
dermatology at the New Jersey Medical School. Dr.
Brodkin retired several years ago. She was honored as
‘Woman of the Year” by the NJMWA in 1964.
Jessie D. Read, M.D. Bom in 1903, Dr. Read was
a gynecologist and obstetrician in Essex County for
over 50 years. She was a founding fellow of the Ameri-
can College of Obstetrics and Gynecology and a fellow
of the American College of Surgeons. Dr. Read was one
of the first women physicians commissioned in the
Army from New Jersey in World War II and served as
chief of surgery of a hospital unit in Europe from 1943
to 1946. She died in 1979.
Mary Bacon, M.D. Bom in 1904, Dr. Bacon served
Bridgeton on a daily 12-hour schedule in general prac-
tice as well as team physician for several local football
squads from 1917 until her death several years ago.
She was president of the Cumberland County Medical
Society and first woman president of the medical staff
of Bridgeton Hospital.
Lena Edwards, M.D. Bom in 1900, Dr. Edwards
continues a long medical career that began as a resi-
dent in obstetrics and gynecology at Margaret Hague
Hospital, Jersey City. She graduated from Howard Uni-
versity. Despite the disadvantage of being female and
black. Dr. Edwards has achieved numerous honors.
Camille R. Mermod, M.D. Bom in 1901, Dr. Mermod
was one of New Jersey’s most distinguished women
physicians. She graduated from Stanford University in
1932 and remained on its faculty from 1932 to 1938
as clinical instructor of medicine. From 1938 to 1943,
she was director of the laboratory at St. Joseph’s Hos-
pital, Lancaster, Pennsylvania She came to Newark as
assistant pathologist at Saint Barnabas Hospital in
1942. During World War II she covered six hospitals
in Newark and surrounding areas as a pathologist.
After the war. Dr. Mermod entered the practice of
internal medicine and stayed in that specialty until her
retirement. She was chief of the department of medi-
cine from 1955 to 1957. Dr. Mermod was a Diplomate
of the American Board of Pathology and contributed
many papers to the literature in the field of
hematology. She was president of the American Medi-
cal Women’s Association twice, 1954 to 1955 and 1956
to 1957. She edited the journal of the association for
many years. In 1959, she was “Woman of the Year” in
New Jersey and in 1965 she was awarded the Elizabeth
Blackwell Medal by AMWA, its highest award. In 1964,
she went to Italy as visiting lecturer at Bologna Medical
School and in 1967 her alma mater. Mills College, Cali-
fornia, conferred the honorary degree of Doctor of Laws
upon her for outstanding work in scientific fields. In
1969, the AMWA announced a new award in Dr.
Mermod’s honor: a bronze medal encased in lucite
given yearly to a layperson who has given outstanding
service to the organization. Dr. Mermod died in 1976
at the age of 75 after a courageous fight with cancer.
Laura E. Morrow, M.D. Bom in 1913, Dr. Morrow
graduated phi beta kappa from Rutgers University in
1932. She completed her medical training at the Uni-
versity of Pennsylvania in 1937. After an internship in
Lancaster, Pennsylvania Dr. Morrow completed a psy-
chiatric residency at St. Elizabeth’s Hospital, Washing-
ton, D.C., and New Jersey Psychiatric Hospital in
Greystone Park. She began her psychiatric practice in
1947 after five years in general practice and still has
a very limited practice. Dr. Morrow was president of the
AMWA in 1969 after many years of active committee
service. She was awarded the Elizabeth Blackwell
Medal in 1974 by the AMWA. She was the first woman
president of the Passaic County Medical Society in
1972 to 1973 and the president of the Society of
Clinical Psychiatrists of Northern New Jersey in 1965
to 1966. Dr. Morrow was married to Dr. J. Lloyd Mor-
row.
Virginia M. Love, M.D. The first black psychiatrist
employed by Essex County in 1955, Dr. Love was a
graduate of Howard University in 1950.
Jerene Robbins, M.D. A graduate of Hahnemann
Medical College, Dr. Robbins was the first woman
physician to be a college men’s team physician at St.
Peter’s, Jersey City. She is a thoracic surgeon, one of
the first in the state.
Emma M. Richardson, M.D. In 1918, Dr. Rich-
ardson fought to gain free medical care for prenatal
patients to reduce high maternal death rates.
Edith D. Mangone, M.D. An obstetrician at
Margaret Hague Maternity Hospital, Dr. Mangone ad-
vocated reduction of maternal deaths by control of
puerperal infection, eclampsia, and hemorrhage. She
wrote papers on these subjects.
REFERENCES
1. Cowen DL: Medicine and Health in New Jersey: A His-
tory. Princeton, NJ, D. Van Nostrand Co. Inc., 1964.
2. Lopate C: Women in Medicine. Baltimore, MD, The John
Hopkins Press, 1968.
3. Flexner A: Medical education. Carnegie Foundation Re-
port, 1910.
4. Brodie JJ: The woman physician in the United States
today. World Medical J 25:28, 1964.
5. Conference on the Full Utilization of the Woman Phy-
sician: Facts on prospective and practicing women in medi-
cine. Washington, D.C., 1968.
6. Nemir RL: Women in medicine during the last half cen-
tury. JAMWA 33:201, 1978.
7. Marrett CB: Nineteen th century associations of medical
women: The beginning of a movement. JAhtWA 32:469, 1977.
8. Brodkin E, Haycock CE, Henle C, LiSooey E: History N.J.
Medical Women's Association Branch Four, AMWA. 1972.
9. Walsh MR: Women physicians and World War II. JAMWA
32:189, 1977.
10. Teffean C: Sophia Presley. M.D.: The spinsterwho strug-
gled seven years against bias of male doctors. Bulletin
Camden County Historical Society 28:36, 1975.
VOL. 81— NUMBER 9— SEPTEMBER 1984
777
r
j
The Journal
of the Medical
Society of
New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jersey. This special
issue illuminates the beginnings of our health care system and the growth
of medical care: essays highlight those talented individuals who devoted
themselves to this system, and commentaries present the development of
specialized care in associated fields of medicine. Plus a special photography
section highlighting three statewide exhibits.
Copies of this issue are available by sending $5.00 (check or money
order) to MSNJ, Two Princess Road, Lawrenceville, NJ 08648. All MSNJ
members will receive one copy of this issue.
Name
Address
Enclose a $ 5.00 check or money order for each copy.
778
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
A Medical Dynasty
in New Jersey
Estelle Brodman, ph.d., hightstown*
There was a large number of physicians practicing in Hightstown
in the late 19th and 20th centuries . A preliminary investigation
showed that no fewer than 1 5 physicians practiced there from
1 886 to the end of World War I. Four families provided most of
the medical care through two generations .
I
Avery large number of physicians
practiced in Hightstown in the
late 19th and early 20th cen-
turies. It would seem that a borough as small as
^ightstown could not have been able to support more
[than a couple of physicians, for at no time during this
period did the population rise above 2,750 people. A
preliminary investigation of the directories of Ameri-
ucan physicians from 1886 to 1920, however, showed
that no fewer than 15 physicians practiced in Hights-
town from 1886 to the end of World War I. Usually,
there were 5 physicians listed for any one year, but
occasionally there might be 6 or even 7. Moreover,
many neighboring smaller communities, some of them
now incorporated into the Hightstown area provided
other physicians, who now and then moved into “the
icity” (Hightstown) as they grew older; so actually there
were more physicians available to Hightstown patients
than the official directories would seem to indicate.
Another finding was that four families provided
medical care through at least two generations; one of
these families had three physicians (including one
woman) and three trained nurses during this period.
In this paper I shall describe some of the conditions
which led to the medical situation described, give some
biographical information about several of the physi-
cians, and then examine the Silver family dynasty of
physicians, and especially. Dr. Sarah C. Silver- White.
HISTORIC HIGHTSTOWN
Hightstown is an old gristmill town, founded orig-
inally in 1721 on the post road which ran from
Camden through Bordentown to Perth Amboy, con-
necting with ferries to Philadelphia at the Camden end
and with New York at the Perth Amboy end. Inter-
secting the Camden to Perth Amboy Road near Hights-
town was the road to York, Pennsylvania through
Trenton. (Both roads were important in the battles of
the Revolutionary War, and a tavern for weary travelers
soon sprang up at their intersection. By 1835, Hights-
town had a post house for the stage line between
Princeton and Freehold; later there were four hotels for
travellers.)
Hightstown continued to be important in the com-
merce between New York and Philadelphia throughout
the 19th eentuiy, partially because one of the earliest
American railroads, the Camden and Perth Amboy
Railroad, ran through town. In addition to the Camden
and Perth Amboy Railroad, the Union Transportation
Company and the Pemberton and Hightstown Rail-
road (later part of the Pennsylvania Railroad system)
ran through or near Hightstown. So important was the
railroad business to the town that the local newspaper,
*Dr. Brodman is a Librarian and Professor of Medical History
Emerita. Washington University School of Medicine, St. Louis.
MO.
VOL. 81— NUMBER 9 — SEPTEMBER 1984
779
the Hightstown Gazette, regularly carried a column,
"Railroad Doings," which noted changes in personnel,
schedules, prices, sales, and accidents. In addition, 2
of the 15 physicians listed primarily were railroad sur-
geons, rather than full-time Hightstown residents'
physicians.
While the railroad was the hub for the agricultural
wealth of the surrounding area — rye, wheat, other
grains, potatoes, and apples— it also allowed physi-
cians to see patients who lived at a distance; either by
themselves going to the patients in other vicinities, or
by having patients come on the railroad for appoint-
ments with Hightstown doctors. By 1906, when the
first automobile was purchased by a Hightstown phy-
sician, the catchment area for patients had expanded
enormously from the early days.
MEDICAL CONDITIONS
Because of its geographical position, halfway be-
tween New York and Philadelphia the influence of
these two cities on Hightstown was considerable: yet
neither city was dominant over the other. Looking at
the education of the 15 physicians under study, we
find 6 were trained in medical schools in Philadelphia
4 in New York, 2 in Maryland, 1 in Ohio, and 2 in
unknown places. As was to be expected, the earlier
physicians were more likely to train in Philadelphia
and the later ones in New York as that city’s schools
began to equal their Philadelphia rivals.
Like many other areas in New Jersey, Mercer County
had few hospitals until World War I. Trenton was the
only Mercer County city with any hospitals at all in
1890: St. Francis Hospital (founded in 1873), the Tren-
ton City Hospital, and the Trenton Eye and Ear In-
firmary. Accidents and serious illnesses were treated
at home or in the local doctor’s office, while many
operations still were being performed in farmhouse
kitchens and dining rooms. Quarantine was practiced
for school children, but not always observed carefully.
In 1897, according to the Transactions of the Medical
Society of New Jersey for that year, Mercer County had
222 eases of diphtheria with 44 deaths; although some
toxin-antitoxin vaccine was available as a preventive,
where it was used the mortality rate from diphtheria
fell from 32.6 to 7.6 percent; 56 cases of scarlet fever;
and 100 eases of typhoid fever. In 1886 the local news-
paper reported that nearly every youngster in town had
whooping cough; in 1890, it reported that “our doctors
are unusually busy with cases of influenza, although
the town itself is not furnishing many of their pa-
tients"—which again shows that the patient popu-
lation extended far beyond the town itself. But by this
time the telephone and electricity were coming into the
town, easing the work of all.
Finally, the local drugstore was advertising not only
that it sold paints and varnishes as well as drugs and
patent medicines (good for man or beast), but that, as
the newspaper noted on February 23, 1888, “Probably
no one thing has caused such a general revival of trade
at Cunningham’s Drug Store as their giving away to
their customers of so many free trial bottles of Dr.
King’s New Discovery for Consumption.”
As might be expected, medicine in Hightstown in
this period was divided by sects as much as in other
areas of the nation with several homeopathic physi-i
eians and one chiropracter. The physician was likely :
to be judged by his perfonnanee rather than his back-!:
ground philosophy, and at least two of the home-
opathic physicians were accepted by both the public
and the medical practitioners, as well as the state
licensing bodies, even though the state medical society
did not encourage homeopaths to become members.!
Dr. George H. Franklin, for example, practiced in
Hightstown for some 30 years as a homeopathic phy-
sician, as did Dr. Sarah Silver White who came back
to Hightstown after practicing homeopathy elsewhere
and was accepted without question.
BIOGRAPHICAL SKETCHES
Although there were 15 physicians practicing in
Hightstown from 1886 through World War I, there were
really only 4 who stayed for any length of time: Doctors
George H. Franklin, Joseph P. Johnson, George E.
Titus, and Lloyd Wilbur.
Dr. George Henry Franklin was bom in 1856 and
received his medical degree from the Columbia Univer-
sity College of Physicians and Surgeons, New York, in
1879. He practiced for a few years in Windsor, a neigh-
boring town: in 1886, he moved to Hightstown and
remained there the rest of his life. Although the general
practice of physicians at that period was to take care
of all cases — and the Hightstown Gazette certainly re-
ports his work in eases of accidents and in
epidemics— Dr. George Franklin reported to the Ameri-
can Medical Association in 1906 that his practice was
limited to obstetrics and gynecology. There is nothing
in the local archives that would clarify this point; on
May 29, 1890, the local newspaper reported that he
had purchased an oxygen generator and planned to
use the gas in chronic lung diseases, bronchitis, inci-
pient consumption, and severe cases of dyspepsia and
rheumatism. Perhaps he changed to specialization be-
tween this date and 1906, but that is speculation. Dr.
Franklin also was a joiner; as an ardent Methodist he
attended many of the church’s annual conferences,
and he frequently talked to the Baptist Men’s Club on
medical and moral subjects. On February 7, 1910, for
example, he spoke on tuberculosis, then a potent killer
in Hightstown. He was on the town council, elected on
the “Improvement Ticket” in 1900, and he served for:
a time as school medical inspector. He called the home
and office he built in 1910 on Main Street a bungalow,
which still stands.
Dr. George H. Franklin had one son, Charles Mon-
tange Franklin (1881 to 1918), who graduated from
University of Pennsylvania Medical School in 1906.
“Monty” Franklin typified the education of Hightstown
physicians, for the family was divided, with one mem-'
ber going to New York for medical training and the
other to Philadelphia; although usually it was the older
physician who had the Philadelphia degree and the!
younger the New York one. Like his father, Dr. Charles
Franklin claimed a specialization — his practice was
limited to pediatrics, complementing, no doubt, his
father’s obstetrical work.
The younger Dr. Franklin was one of the town’s gay
blades, for the newspaper reports a number of his
actions as a young boy and later as an adult, when he
780
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Figure 1 — Home and office of George E. Titus, M.D.
and his wife gave rather elaborate dinner parties. Un-
fortunately, however, he died during the flu epidemic
of 1918 when he was only 37 years old.
The second long-acting Hightstown physician was
Dr. Joseph P. Johnson, a homeopathic physician who
was graduated from Hahnemann Medical College,
Philadelphia, in 1867 and practiced in Hightstown
until 1912. In addition to his medical practice, of
which details are meager, he was a member of the
school board and clerk of the district for 20 years.
When he declined to run again, in 1900, the Hights-
town Gazette noted, “He has done an immense
amount of hard work and shown a deep and intelligent
interest in our public schools.” On March 20, 1890,
“sealed bids for doctoring the poor of the township
were presented [to the Township Board] and the con-
tract was awarded to Dr. J.P. Johnson as the lowest
bidder at $43.50.” Whether his contract was awarded
him annually thereafter is not known, nor are his
duties spelled out. As a homeopath. Dr. Johnson was
not a member of the county or state medical societies,
but he certainly was accepted by the townspeople with
the same enthusiasm that they accepted the other
long-term practitioners.
The third long-term Hightstown physician. Dr.
George E. Titus (1855 to 1916) and a graduate of
Bellevue Hospital Medical School, class of 1877, prob-
ably was the most sanitarian-like physician of the
group. He persuaded the town to put in a filter system
for its water supply and later a sewer system. On Janu-
aiy 4, 1900, he was authorized, as chairman of the
town’s Finance Committee, to arrange for certificates
of indebtedness of $2,500 to pay for the filter and he
made regular reports on the matter. He also was active
as a member of the County’s Republican Committee
for a number of years, where he tried to have sanitary
measures put into legislation. Soon after he came to
Hightstown, he erected a handsome house and office
(Figure 1), which still stands on Main Street, in which
he lived until his death in 1916.
Dr. Lloyd Wilbur (1831 to 1900), the last of the long-
term physicians, represents a bridge from the older
education and practice of medicine in the early 19th
century to the newer systems of the late 1 9th and 20th
centuries. He was bom in 1831 in a rural portion of
the state and was educated at the Trenton Academy
and the Pennington Seminary, from which he was
graduated in 1848. He taught school near there for two
years while also studying medicine under Dr. George
F. Fort of New Egypt as preceptor. (Fort later became
governor of New Jersey, showing how medicine and
politics still were possible joint occupations at the
time.) In 1853, Lloyd Wilbur entered Jefferson Medical
College, Philadelphia from which he obtained his
degree in 1854 after the usual two-year course. Later,
Princeton University awarded him an honorary master
of arts degree for his civic as well as medical efforts.
Dr. Wilbur was an ardent abolitionist, and was a
member of the Republican delegation to the conven-
tion which nominated Abraham Lincoln for the presi-
dency. He was Superintendent of Schools for Mercer
County for six years, and State Superintendent of the
School Census until that office was abolished by the
legislature. In 1887, the borough of Wilbur was named
for him, now a part of Trenton.
Wilbur’s medical practice is better documented than
that of the other physicians. His ledger of patients and
charges made has been preserved and is in the Hights-
town Historical Society. Since primarily it is a fiscal
accounting, the ledger does not give all the medical
details which we would like to have; moreover, it covers
a period when he was just beginning his practice
(1857 to 1860). There are enough data in the book to
derive some conclusions about his practice— and,
therefore, probably the practice of other physicians in
small towns at that time.
Since Dr. Wilbur bought the practice of a Dr. Blauvelt
in 1855, it is possible that he inherited some of that
physician’s clientele. I have tabulated his records for
the first three weeks of August, for 1857, 1858, and
I860;
1 . He saw from 1 to 1 0 patients a day, growing stead-
ily busier. In 1857, his average load was 2.95 pa-
tients/day; in 1858 it was 3.3/day, while in 1860 it was
4.6. The latter year must have been a particularly sickly
one, because he listed more than 4 patients/day on 6
of 21 days, some even on Sunday, and he had several
10-patient days.
2. He saw the same patient on the average of five
consecutive days, after which it is presumed the pa-
tient was discharged.
3. His usual charge for a visit and medicine, or a
visit and advice, was 50<t. A visit to two patients in a
household varied from 75<t to $1.50. Night calls were
$2 to $5, and obstetrical cases were $5. Variations
occurred, of course; clergymen were not charged any-
thing and colored patients 12‘/2<t a visit. It should be
emphasized, of course, that these were just his
charges: payments were rarely as much as the ledger
indicated, and here and there barter payments in-kind
were noted — grain, chickens, and ham.
4. Occasionally, the disease and/or its treatment is
listed. Some causes for the fees are given, as; removal
of foreign body or “accouchement uxoris" (billed, of
course, to the husband). Tincture of opium was given
to one patient who was charged 37I/2<L though spirits
of ether cost another patient 50<t and I lydr. ehlor. and
Acct. Potass, each were only 25C. An incision of the
aveolar (perhaps lancing a boil on the gum) cost one
father another SOtf and extracting a tooth cost another
781
VOL. 81— NUMBER 9 — SEPTEMBER 1984
The Silver family (Figure 2) contributed the most
medical and heal tin related care to the residents of
Hightstown during this period.
The oldest member of the group was Dr. George Ad-
dison Silver (1861 to 1944) (Figure 3). a graduate of
the New York University Medical College in 1881. For
some years he was in practice in Butler, Morris County;
then he moved to Windsor, the suburb of Hightstown,
where he practiced until he came to Hightstown in
1909.
Dr. George A. Silver’s son. Dr. E. Drew Silver, bom
in 1889, received his medical degree from the College
of Physicians and Surgeons in Baltimore in 1913. Dur-
ing World War I he served in the Medical Corps as-
signed to the British Black Watch. While in Europe, his
wife and daughter continued to live in Windsor, often
visiting Hightstown for Sunday family reunions. After
returning from the War. Dr. E. Drew Silver (Figure 4)
moved his family and practice to Hightstown.
Three of the Silver family women became nurses:
Josephine Drew Silver, Jane Amanda Silver, and Marie
Pullen Silver. The New York-Philadelphia education !
balance can be seen in the training of these three
women: Josephine and Jane Amanda were in the sec-
ond class of the newly formed Nurse's Training School
at Bellevue Hospital, New York. Marie was a graduate
of the Philadelphia’s Women's Hospital. During World
War I, Jane Amanda nursed in Gouvemeur Hospital,
New York, and later became office nurse for her sister.;
Marie Pullen Silver was the wife of Dr. E. Drew Silver.
One can only speculate whether these three women
who became nurses just before the turn of century
might not have wished to enter the medical profession
directly, but were constrained by the mores of the time
and the consequent difficulty of finding a reputable
medical school that would take medical students. I call
to your attention the fact that women’s medical
schools proliferated because no other way of obtaining
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
husband 25<L A spontaneous abortion caused Dr.
Wilbur to ask one husband for Si and another hus-
band for S2. Tincture of digitalis was prescribed:
morphine was injected; a ease of tetanus treated; neu-
ralgia was listed once; and diarrhea and convulsions
each once. He adjusted a fracture of the clavicle for one
patient at a charge of S5, while seven consecutive visits
to the unnamed “milkman” with an unlisted disease
were charged at $5.50.
Dr. Lloyd Wilbur died on Januaiy 27, 1900, and re-
ceived a two-column obituaiy in the local paper and
a funeral attended by patients and other physicians
from throughout New Jersey. The Medical Society of
New Jersey representative characterized Dr. Wilbur as
a truly accomplished practitioner with a vice-like mem-
ory, accustomed to constant study and often in consul-
tations with the foremost doctors of the eountiy. His
ideas and opinions were said to be clear-cut; in surgery
he was found to be original, dextrous, and resourceful.
The lay paper commented on his humane qualities:
"Under a natural bmsqueness of manner, he concealed
a heart that was as tender as a woman’s, and his
notable indifference to charging fees or collecting bills
has made many a poor man and woman call his name
blessed.”
Dr. Wilbur had two sons, both of them physicians.
The older practiced in Asbury Park and the younger
continued his father’s practice in Hightstown. Dr. Wil-
liam Wilbur, the younger son, was a graduate of the
University of Pennsylvania in 1888 and returned to
practice in Hightstown until 1906 and again after
1918. Like his father, he was a politician as well as a
physician, being sheriff of Mercer County for a number
of years and finally becoming president of the New
Jersey Sheriff s Association. He moved to Trenton in
1906 and practiced there as well as in Hightstown for
some years. While in Trenton, some of his Hightstown
patients came to that office on the train and by bus,
according to one resident. Dr. William Wilbur made
several foreign trips— to London and Paris three
months after his father’s death, and then continued
on to Oberammergau for the Passion Play. He was
certainly up-to-date, going to New York for the Auto-
mobile Show of 1906 and buying a Buiek for himself.
SILVER FAMILY MEDICAL DYNASTY
Figure 2 — Silver family photograph.
Figure 3 — George A Silver, M.D.
782
Figure 4 — E. Drew Silver, M.D.
! a medical education existed, with even Johns Hopkins
Medical School playing tricks with the money Mrs.
Garrett gave them on the condition that they admit
women equally with men, to emphasize the frustrating
position of the women in the Silver family who might
have had the same bent as their male siblings.
One of the Silver women, however, did not follow the
line of the acquiescing females— she became a phy-
sician on her own after some years as a nurse and
practiced medicine for 38 years in New York and sev-
eral New Jersey cities. She was Sarah Cubberley Silver,
M.D., — after her marriage, she practiced as Silver-
White.
Bom two years after her brother. Dr. George Addison
Silver, Sarah Silver (1863 to 1933) was graduated at
age 32, in the 1895 class of the New York Medical
College and Hospital for Women, a homeopathic in-
stitution which had been founded in 1863; the College
had 16 professors, 4 assistant professors, 6 lecturers,
1 demonstrator, and 1 assistant demonstrator— both
men and women — on the faculty when she was a stu-
dent there. Unlike many of the medical schools of the
time, this one had a 4-year graded course with a 26-
week academic year, and advertised it had laboratories
for the study of anatomy, histology, and elin-ical medi-
cine. Matriculants were expected to have a college
degree or have passed the New York State Regents
examinations, although like many medical schools of
the time, the stated requirements and the actual ones
probably differed. For the period, however, this school
was at least as good as many of those which accepted
men only.
Figure 5 — Sarah C. Silver-White, M.D.
For almost a year after her graduation Sarah Silver
remained at the hospital run by the medical school in
New York City; in 1896, she moved to Paterson. From
1896 to 1902, she lived at four different addresses in
Paterson. At that point she returned to New York City
and practiced under her married name, Silver-White,
at three different places through 1909. By 1912 she
was resident in Passaic, and had two different ad-
dresses in that city until, after a heart attack, she
returned to practice in Hightstown in 1916: but even
in that town she managed to live at three locations
until her death at 70 years of age in June 1933 of a
brain tumor. She ceased to practice in 1930. When
asked about all these changes of address, her grand-
niece said Dr. Sarah was a perfectionist; for her
nothing was ever right. The niece also admitted, how-
ever, that Dr. Silver-White was a very difficult woman
to get along with at any time, and that probably ac-
counts for her moves (Figure 5).
Apparently, Dr. Silver-White was a good physician,
even if a peculiar one, and adored by her patients.
There is one story told about how she visited a sick
child in the country and went out of the fannhouse
to speak to the child’s father who was plowing. To her
surprise, however, she found that the father also was
ill with the same high fever, and she ordered him to
go home and go to bed. When he complained that he
must finish his ploughing first, she told him to go
home— she would do the rest of the ploughing, and she
did!
Patients that she had treated at her Paterson or
Passaic practices still came to her in Hightstown for
medical help, using the railroad until buses and auto-
mobiles came in. For that reason she had her office
close to the railroad station and is reputed to have
learned the railroad timetables by heart. Her sister.
Jane Amanda, the trained nurse, acted as her office
nurse, and is said to have made the patients’ and the
local merchants’ lives easier than did her rather short-
tempered sister.
CONCLUSIONS
What final conclusions can we draw from this tale
of local New Jersey physicians in the decades around
the turn of the 20th century? I think we can conclude
that:
VOL. 81— NUMBER 9— SEPTEMBER 1984
783
1. While none of the physicians I have discussed
made any great additions to medical knowledge or pub-
lished or experimented anything notable, they rep-
resented the ideal of the family physician which in
today's world is so difficult to find.
2. Even in small towns in New Jersey, the physicians
generally were well-educated, either in allopathic or
homeopathic medicine.
3. Most small town physicians were general practi-
tioners, and even those who stated that they limited
their practice were expected to remain the family phy-
sician as well.
4. The practice of medicine at that time was not so
compelling but that physicians had time to take or
civic, religious, and societal roles not so common today
5. As communication and transportation methods
grew better, the catchment area for physicians to draw
patients enlarged greatly. The railroad was the princi
pal aid here until the time when the public transpor
tation bus and the automobile became competitive.
6. Women still were being relegated to supporting
roles in medicine at this time, although an oceasiona
woman physician can be expected.
7. Just as tradesmen and craftsmen tended to pass
on their skills to their sons, so physicians often buil
medical dynasties.
784
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Academy of Medicine of New Jersey:
A Brief History
Morris H. Saffron, m.d., lawrencevtlle*
The Academy of Medicine of New Jersey (AMNJ) is a beacon of
enlightenment for the practicing physician. From its beginnings
to the present time, AMNJ has worked for the dissemination of
medical information.
When the Academy of Medicine of
New Jersey (AMNJ) was founded
in 1911, New Jersey, one of the
few remaining states without a medical school, was a
jprofessional wasteland. Only Newark City Hospital had
acquired national recognition as a center of medical
education. The fathers of AMNJ. who included the
most distinquished physicians of northern New Jer-
sey, made it clear from the very start that the primary
purpose was “the dissemination of medical infor-
mation to the profession and the public.” From this
objective, AMNJ never has waivered and decades before
the concept of an enforced CME was even considered,
the organization had become a beacon of enlighten-
ment for the practicing physician.
AMNJ was founded in Newark and originally was
called the Academy of Medicine of Northern New Jer-
sey. Its purpose was to provide a place for scientific
meetings where practicing physicians could continue
their education. An eyewitness account from an early
cublication describes the beginning:
“It was one cold, wintry night on February 25,
1911, that some determined, dedicated knowledge-
thirsty doctors came streaming intp the Newark
public library, some walking across Washington
Park from the fashionable houses, that, in those
days, were located in the downtown section of New-
ark. Some came on bicycles, some in buggies, and
some chugged along Washington Street in high-
fendered, open-top automobiles. They came from
Newark and Jersey City, Hilton and Communipaw,
Elizabeth, and Vailsburg. By ten o’clock there were
nearly 100 of them, crowded into a shelf-lined cor-
ner, perched on chairs and stools and book boxes,
eager to give the breath of life to the age-old idea
of an Academy of Scholars.”
This formal debut of the Academy brought together
a distinguished group of men. Dr. Edward J. Ill, the
distinguished surgeon and humanitarian, was the
first president. The early meetings were held in the
first home of the Academy, the Wiss Building at 671
Broad Street, and the roster of speakers during the
early days indicates the high standards set by the
founders. The first formal address was given on No-
vember 2, 1911, by Dr. John B. Murphy, the famous
Chicago surgeon, then president of the American
Medical Association.
But the main purpose of the Academy— the op-
portunity for free and open discussion— could not be
served through formal lectures alone. April 19, 1911,
saw the formation of four original sections: medicine:
surgery; obstetrics and gynecology: and ear, nose, and
throat. In 1915, pediatrics became a new section. By
1950, three additional sections were added: general
practice; oral medicine and surgery: occupational
medicine and hygiene; additional sections since have
been added.
*Dr. Saffron is Guest Editor of this special issue.
70 L. 81— NUMBER 9— SEPTEMBER 1984
785
THE EARLY YEARS
Academy President August Strasser left in 1917 to
serve in the armed forces; the Academy was left under
the able administration of Harrison Martland, M.D. Six
scheduled meetings were cancelled because no
quorum was available (wars notoriously have harmful
effects on voluntary organizations) and the only large
conference held was that of the pediatric section. The
shortage of physicians was felt more keenly because
of the calamitous influenza epidemic which ravaged
New Jersey during 1918 and 1919. This menace
brought forth on February 19, 1919, one of the greatest
symposia ever held at the Academy; the entire subject
of influenza was covered from every conceivable aspect.
During these troubled years the Fellows never lagged
in the pursuit of a permanent home for the Academy.
President Harry B. Epstein led a successful campaign
for subscription funds for the purchase of a
brownstone facing Lincoln Park, and on October 20,
1920, President John F. Haberty opened the doors to
a brilliant assembly (Figure 1).
By an agreement signed May 18, 1921, the Medical
Library Association was merged formally with the
Academy, and the books were transferred to the new
building. With the acquisition of a handsome home
and fine library — then valued at $10,000 — the
Academy entered on the second prosperous phase of
its history.
With inadequate financial resources, the 18-year-old
Academy was ill prepared to meet the depression years
of 1929 to 1933. Mass resignations reduced revenue
to such a degree that a committee was formed belatedly
to obtain funds for a permanent endowment. Still, in
1930, the Academy voted to send a gift of books to the
library of the newly opened Temple University School
of Medicine, a brave gesture in those difficult times.
Between 1935 and 1937, President Max Danzis
began an intensive public relations program which
brought thousands of lay people to Academy meetings.
By 1936 signs of true recovery were in evidence. The
city of Newark resumed its financial support of the
Academy Library, discontinued in 1933.
With improving economic conditions, 1937 also saw
an unequalled rise in the number of new members. In
a drive sparked by President Hemy C. Barkhom, over
100 new Fellows joined, bringing the total to 474.
In 1939, on the 85th birthday of Dr. Edward J. Ill,
an award bearing his name was established by the
Academy (Figure 2); the honor is bestowed annually
upon a New Jersey physician for dedication and ex-
traordinary service to the profession and citizens of
the state.
THE 1940s
The 30th anniversary of the Academy was high-
lighted by the announcement of the Eagleton gift on
March 18, 1941: the brownstone adjacent to the
Academy home— doubling the space for the library and
meetings. With the acquisition of the Eagleton House
rose the necessity of integrating the two struc-
tures—accomplished by 1942.
The years of World War II brought serious problems
and drastic changes. The Academy founding fathers
were becoming too ill and feeble to continue in active
Figure 1 — The Academy's first permanent home.
service. Since the majority of youthful Fellows were1
called to active duty, the roll of dues-paying members
fell to a distressingly low point. Under the adminis-
tration of Dr. Royal S. Schaaf (1944 to 1945), the down-
ward trend in membership was checked.
In September 1945, President Lee Hughes acted as
host at a formal reception to returning war veterans. I
These men came back with an insatiable appetite for
knowledge, determined to resume their studies, and to
embark on a career of specialization.
THE 1950s
The years 1951 and 1952 saw several large acquisi-
tions by the library; 1,000 volumes from the library of
Dr. Edgar Cardwell; 1,500 volumes from Princeton Uni-
versity; and the entire collection of the defunct Essex
County College of Medicine and Surgery. In antici-
pation of a move from Newark to a more accessible
suburban area, the agreement with the Newark Library
was terminated.
On March 5, 1953, the name of the Academy was
officially changed to the Academy of Medicine of New
Jersey (AMNJ).
On January 7, 1954, Dr. Herbert A. Schulte reaf-
firmed the position of the Academy stating: “Post-
graduate education be considered a fundamental func-
tion of the Academy, that our efforts and capacities be
extended through existing or new avenues to correlate
and integrate all our activities to make them available
throughout the state, and that we implement pro-
grams in order to avoid duplication and inevitable dis-
persion of interest on the part of the medical pro-
fession." This led to the formation of a committee on
education.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
786
Figure 2 — Wells P. Eagleton, the first recipient of the Edward
J. Ill Award.
On April 7, 1955, the Academy established the
“Citizen’s Award,” to be given annually to a New Jersey
resident for extraordinary individual services for the
health and welfare of the general public.”
In October 1959, the Academy moved to Bloomfield,
to larger quarters.
THE 1960s
When Dr. Morris Saffron was president (1965 to
1966), MSNJ had begun to give some financial support
to the Academy library, yet there still was no formal
understanding relative to postgraduate education, a
subject in which both organizations were vitally con-
cerned. Drs. Parsonnet, Bernhard, and Saffron eventu-
ally gained financial assistance from the Medical So-
ciety for expansion of an educational program — an al-
location to support visiting symposia The Academy
was on the way to its present supremacy as a center
for the dissemination of medical information.
During the term of Dr. W. Franklin Keim as president
(1967 to 1968), the first presentation of the William
P. Burpeau Award, established by the section on urol-
ogy as a memorial to a New Jersey leader in this
specialty, was made; the award since has been given
annually to an impressive list of urologists from
foreign countries as well as our own.
THE 1970s
As the Academy entered what has proved to be the
most eventful decade of its histoiy, it already had at-
tained a position of leadership as the most influential
force in the field of continuing medical education
CME) with the help of Dr. Milton Shoshkes who was
parrying CME programs to unprecedented heights. Yet
despite the continued rise in membership, the
Academy still found itself in a chronic state of financial
difficulty. With minimal endowment, AMNJ depended
on dues for 90 percent of its budget, more than
$50,000 of which went to support the library. Although
this was the rock on which the Academy had been
founded, and a continuing source of pride when it was
the only major collection in New Jersey, it rapidly was
being surpassed by the two libraries of the state-sup-
ported medical schools. Finally, the actual transfer of
some 40,000 volumes to Newark was necessary and
effected; the rare books were appraised and the collec-
tion was deposited for a five-year period in Newark,
with the understanding that it could be recaptured in
the event that the Academy found suitable quarters.
In December 1970, the Board adopted a resolution
prepared by Dr. Hemy Davidson, outlining the
Academy’s obligations as the recognized educational
arm of MSNJ. The Academy agreed to consult with and
present annual reports of its activities and expen-
ditures to the Committee on Education of the Medical
Society, which would have representation on the
Academy Board; Dr. James A. Rogers was the first
liaison member.
At the same time, the Bulletin, the Academy journal
started in 1955, was published for the last
time— another sacrifice to economic necessity; it con-
tained six articles on various aspects of New Jersey
medical history.
When Dr. Sherman Garrison assumed the office of
president (1971 to 1972), the unsatisfactory fiscal
status demanded his immediate attention. He ap-
pointed Dr. Leo Siegel to head a committee to negotiate
with potential buyers for the sale of the Bloomfield
property, and terminated all library activities. AMNJ
played host to a team sent out by the AMA to survey
programs; on August 7, 1972, the Academy received
approval as a category I sponsoring organization for
a period of four years. At the same time MSNJ in-
stituted a mandatory requirement of 150 hours of ap-
proved study every three years for continuing member-
ship. Taking note of these rapid developments in the
field of education. Dr. Siegel voiced his determination
that the Academy maintain its leadership in CME,
urging younger Fellows to advance new ideas for con-
sideration.
In the spring of 1973, Charles Heitzmann was ap-
pointed Executive Director with Linda Bartolo as his
Associate.
In 1973, the Academy moved to Union. Located some
15 miles south of Newark, the Academy had left Essex
County for the first time, thus demonstrating its de-
termination to serve physicians from every part of the
state. Union was to remain the “interim home" for six
years, during a period marked by unusual activity and
growth.
Upon the death of Dr. Henry Davidson in the sum-
mer of 1973, Dr. Arthur Bernstein assumed the presi-
dency and served another tenn, 1974 to 1975.
In 1974, the Academy of General Dentistry gave its
approval to the Academy as their statewide accrediting
body. This year was also a time of expansion of services
to speciality societies, and in 1984 there are 28 special-
ty societies being served by the Academy.
70 L. 81— NUMBER 9— SEPTEMBER 1984
787
The presidency of Dr. Leon Smith (1977 to 1978)
coincided with a period of unusual growth of member-
ship and activity, and has been called the most pro-
ductive year in Academy history. During this year there
were no less than 12 major symposia some 200 roving
symposia and 900 cosponsored meetings.
During his term in office, President James A. Rogers
(1978 to 1979) addressed several messages to the Fel-
lows in which he touched on CME, the increasing
incursion of government bureaucracy in the practice
of medicine, the escalating cost of the health delivery
system, and the necessity for the profession to col-
laborate in presenting a solid front against detractors.
In view of the increasing number of specialty so-
cieties affiliated with the Academy in 1979, it had been
suggested that AMNJ sponsor a New Jersey Associa-
tion of Medical Specialty Societies. This group was
organized on February 14, 1979, and thus became an
added force supporting the efforts of organized medi-
cine to keep CME under the direct control of the prac-
ticing physician.
In September 1979, after six years in Union, the
Academy finally moved to the headquarters of the
Medical Society of New Jersey in Lawrenceville. The
advantages were manifold: adequate parking facilities:
ample office space for the expanding staff; conference
rooms; an auditorium seating 400; a dining area; and
storage room. Of even greater significance was the fact
that the Academy, now officially designated as the
educational arm of MSNJ, could work closely with the
administrative staff of that Society. Finally, this central
location symbolized a determination to become an
Academy for all of New Jersey.
THE PRESENT YEARS
AMNJ, with 2,200 members now is actively studying
the new developments in computer technology to see
whether they can be adapted to home and office use
as educational tools. Thus, AMNJ is planning to offer
audio cassettes to Fellows which will include the more
important symposia And for the general public there
is a roster of 80 speakers who can discusss health
topics before clubs and other civic groups. Finally,
AMNJ Past-President, Dr. Paul Hirsch, instituted reg-
ular luncheon meetings devoted exclusively to
nonelinical socioeconomic topics and these already
have proved to be a new and successful development.
CONCLUSION
The perceptive words of Dr. C.M. Robbins, written 50
years ago, sum up the history and purpose of the
Academy: The very existence of the Academy is a token
of our interest in keeping ourselves members of a
learned profession, and so long as we are a genuinely
learned profession, we can take pride in our title and
need fear no commercialization, no cheapening, no
regimentation. But no one can merit the designation
‘learned’ nor keep the respect of an increasingly sci-
ence-conscious public if he lets his reservoir of techni-
cal knowledge become obsolete. And here is the rea
function of our Academy: To furnish a forum for scien
tific discussion, a channel for the newest medical anc
dental data, a training center for the intellectually
curious and the tools for the resharpening of our pro;
fessional wits.”
788
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
BALANCED
CALCIUM
BT
Low incidence of side effects
CARDIZEM® (diltiazem HC1)
produces an incidence of adverse
reactions not greater than that
reported with placebo therapy,
thus contributing to the patient’s
sense of well-being.
*Cardizem is indicated in the treatment of angina pectoris due to
coronary arteiy spasm and in the management of chrome stable
angina (classic effort-associated angina) in patients who cannot
tolerate therapy with beta-blockers and/or nitrates or who remain
symptomatic despite adequate doses of these agents.
References:
1. Strauss WE, McIntyre KM, Parisi AE, et al: Safety and efficacy
of diltiazem hydrochloride for the treatment of stable angina
pectoris: Report of a cooperative clinical trial. Am J Cardiol
49:560-566, 1982.
2. Pool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise-
inducible chronic stable angina with diltiazem: Effect on treadmill
exercise. Chest 78 (July suppl):234-238, 1980.
Reduces angina attack frequency
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test, 2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (PC.005).
CARDIZEM
(diltiazem HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
Please see full prescribing information on following page.
PROFESSIONAL IISE INFORMATION
cardizem
(dilhazem HCI)
30 mg and 60 mu tablets
DESCRIPTION
CARDIZEM (diltiazem hydrochloride) is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist). Chemically
diltiazem hydrochloride is 1,5-Benzothiazepin-4(5H)one,3-(acetyloxy)
-5-|2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+) -cis-. The chemical structure is:
Diltiazem hydrochloride is a white to ott-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform.
It has a molecular weight of 450.98. Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administration.
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle.
Mechanisms ol Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovine-induced cor-
onary artery spasm are inhibited by CARDIZEM.
2. Exertional Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads.
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect. The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases in peripheral resistance.
Hemodynamic and Electrophysiologic Eflects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrioventricu-
lar conduction in isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate-blood pressure product for any given work load.
Studies to date, primarily in patients with good ventricular function,
have not revealed evidence of a negative inotropic effect; cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
of diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater than first-degree
AV block. Diltiazem-associated prolongation of the AH interval is not
more pronounced in patients with first-degree heart block. In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine. In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins. Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxin, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration. The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours. Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem. Therapeutic blood levels of
CARDIZEM appear to be in the range of 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given; a 1 20-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment of spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM bas been effective in controlled trials in
reducing angina frequency and increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a functioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1 Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome. This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0.48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2 Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited. Caution should
be exercised when using the drug in such patients.
3 Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4 Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals. The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued. In dogs,
doses of 20 mg/kg were also associated with hepatic changes;
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated. Available data are not sufficient, however, to predict
the effects of concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities. In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment ot Fertility. A
24-month study in rats and a 21-month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests No intrinsic effect on fertility was observed
in rats.
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women; therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded.
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition. In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are: edema (2.4%),
headache (2.1%), nausea (1.9%), dizziness (1.5%), rash ,
asthenia (1.2%), AV block (1.1%). In addition, the following
were reported infrequently (less than 1%) with the order of pm
tion corresponding to the relative frequency of occurrence.
Cardiovascular:
Nervous System:
Gastrointestinal:
Dermatologic:
Other:
Flushing, arrhythmia, hypotension, bi
dia, palpitations, congestive heart \f
syncope.
Paresthesia, nervousness, sorting
tremor, insomnia, hallucinations, and a
Constipation, dyspepsia, diarrhea, vfn
mild elevations of alkaline phosphatasr f
SGPT, and LDH.
Pruritus, petechiae, urticaria, photosei n
Polyuria, nocturia.
The following additional experiences have been noted:
A patient with Prinzmetal's angina experiencing epis
vasospastic angina developed periods of transient asymt >
asystole approximately five hours after receiving a single t
dose of CARDIZEM
The following postmarketing events have been reporte h
quently in patients receiving CARDIZEM: erythema multifor e
kopenia; and extreme elevations of alkaline phosphatase (
SGPT, LDH, and CPK. However, a definitive cause and effect ; i
these events and CARDIZEM therapy is yet to be establish1
OVERDOSAGE OR EXAGGERATED RESPONSI
Overdosage experience with oral diltiazem has been
Single oral doses of 300 mg of CARDIZEM have been well h
by healthy volunteers. In the event of overdosage or exac a
response, appropriate supportive measures should be emp ■
addition to gastric lavage The following measures may be cop t
Bradycardia
High-Degree AV
Block
Cardiac Failure
Hypotension
Administer atropine (0.60 to 1.0 mg), t
is no response to vagal blockade, ad t
isoproterenol cautiously.
Treat as for bradycardia above. Fixi j
degree AV block should be treated v j
diac pacing
Administer inotropic agents (isopro i
dopamine, or dobutamine) and diureti
Vasopressors (eg, dopamine or leva:'
bitartrate).
Actual treatment and dosage should depend on the severi I
clinical situation and the judgment and experience of the I
physician.
The oral/LD50's in mice and rats range from 415 to 74( /
and from 560 to 810 mg/kg, respectively. The intravenous I s
these species were 60 and 38 mg/kg, respectively. The ora
dogs is considered to be in excess of 50 mg/kg, while leth;
seen in monkeys at 360 mg/kg. The toxic dose in man is noj
but blood levels in excess of 800 ng/ml have not been as
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atheroscleroti
nary Artery Disease or Angina Pectoris at Rest Due I
nary Artery Spasm. Dosage must be adjusted to each i
needs. Starting with 30 mg four times daily, before meal
bedtime, dosage should be increased gradually (given ir
doses three or four times daily) at one- to two-day intent
optimum response is obtained Although individual patiej
respond to any dosage level, the average optimum dosarj
appears to be 180 to 240 mg/day.There are no available data
ing dosage requirements in patients with impaired renal on
function. If the drug must be used in such patients, titration sl
carried out with particular caution.
Concomitant Use With Other Antianginal Agents:
1. Sublingual NTG may be taken as required to abci
anginal attacks during CARDIZEM therapy.
2 Prophylactic Nitrate Therapy -CARDIZEM may t
coadministered with short- and long-acting nitrates, II
have been no controlled studies to evaluate the anjj
effectiveness of this combination.
3. Beta-blockers. (See WARNINGS and PRECAUTIONS/
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles of If
0088-1771-47) and in Unit Dose Identification Paks of I'd
0088-1771-49) Each green tablet is engraved with MARIOI
side and 1771 engraved on the other. CARDIZEM 60-mi;
tablets are supplied in bottles of 100 (N9C 0088-1 772-47) ail
Dose Identification Paks of 100 (NDC 0088-1772-49). Eat
tablet is engraved with MARION on one side and 1772 on I n
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES, INC
KANSAS CITY, MISSOURI 64137
IIedical Education of New Jersey:
'He Development of UMDNJ
Stanley S. Bergen, jr., m.d., Newark*
The history of the University of Medicine and Dentistry parallels
the development of health professions education in New Jersey.
This article will discuss the past and present achievements of
nedical education in the Garden State.
i
Tthe history of the University of
Medicine and Dentistry of New
Jersey (UMDNJ) parallels the de-
lopment of health professions education New Jersey,
eated to consolidate and unify all of the state’s pub-
programs in medical and dental education, UMDNJ
as founded in 1970 by an act of the state legislature
the College of Medicine and Dentistiy of New Jersey
MDNJ). In 1981, it was granted status as a free-
anding university, in recognition of its growth and
velopment as a statewide system for health.
The creation of a public university fully devoted to
e health sciences was a landmark in the history of
e state. Throughout New Jersey’s history, no school
medicine had survived to celebrate its decennial,
lere were several unsuccessful attempts during the
5th and 19th centuries — including two by Princeton
diversity and three by Rutgers University— to estab-
;h such programs, but the history of health sciences
lueation had been one of benign neglect.
An underlying barrier to the establishment of pro-
ssional education programs was the attitude of the
tizenry; perhaps because of the state’s proximity to
?w York and Philadelphia with their numerous pro-
ams, New Jersey did not need its own medical and
mtal schools. For centuries, young New Jerseyans
ere sent to other states for professional education, on
ie assumption that sufficient numbers would return
settle and practice in the state.
By the mid-20th century, however, it was becoming
increasingly clear that this strategy was not working.
With 109.1 physicians in private practice per 100,000
citizens, the state already had fallen below the national
average; while the ratio of 1 dentist per 1,533 persons
was considered good, studies had shown that alarming
numbers of practitioners in both professions were 50
years of age or older.
The state also found itself lacking many of the other
benefits which are engendered by the presence of a
medical school: the sophisticated specialty care pro-
grams which often are beyond the resources of com-
munity hospitals; the swift implementation of new
techniques and equipment; and the initiation of re-
search and prevention programs geared specifically to
the state’s needs.
In 1950, a study commissioned by Governor Alfred
E. Driscoll favored a state-sponsored medical school,
based on emerging trends of physician shortage and
projected health needs. Among other findings, this
study formally dispelled the long-standing belief that
New Jersey was prohibited from having a medical
education program because of antiviviseciion laws.
Despite the findings of the Driscoll study, no action
was taken toward establishment of a program. The
state’s citizens were not ready to accept the concept
of a publicly funded medical school. This still was dem-
*Dr. Bergen is President of IJMDNJ.
3L. 81— NUMBER 9— SEPTEMBER 1984
791
onstrated clearly in 1954 when a referendum endorsed
by Governor Robert B. Meyner, which would have
provided $25 million for a state medical school, was
rejected by the voters.
In that same year, the gauntlet was taken up by a
private institution, Seton Hall University, a Catholic
institution supported by the Archdiocese of Newark.
Chartered in 1954, the Seton Hall College of Medicine
and Dentistry, based at the Jersey City Medical Center,
enrolled its first class of 80 medical and 40 dental
students in 1956. A second private school, Fairleigh
Dickinson University, enrolled its first class of 45 den-
tal students in the same year. With the inauguration
of these programs, many New Jerseyans were content
to let the responsibility for providing the state’s future
health manpower rest in private hands.
This attitude was not shared, however, by Governor
Meyner. In 1959, the Bane report, issued by the Sur-
geon General’s Consultant Group on Medical Educa-
tion, found that New Jersey would need two additional
medical schools by 1970, just to maintain current
ratios, and that the two existing dental schools would
have to continue and triple their current combined
enrollments. The report reinforced the Governor’s be-
lief that positive steps were needed to head off a critical
shortage of health manpower in the state.
THE PLANNING YEARS: 1961 TO 1964
In 1961, Governor Meyner commissioned a feasibili-
ty study by a special faculty committee of Rutgers Uni-
versity. The panel, headed by the late James H.
Leathern, Ph.D., who then was director of the bureau
of biological research at the State University, brought
forward a plan for an innovative, two-year medical pro-
gram under Rutgers auspices, to be built on what now
is the University’s Piscataway campus.
On June 27, 1961, the plan was transformed into
reality when a grant of $1,073,200 was announced by
the W.K. Kellogg Foundation of Battle Creek, Michigan.
Half of the grant funds were earmarked for planning
and adding faculty to strengthen Rutgers existing de-
partment in the biological sciences and to set up new
departments of anatomy, pathology, and pharma-
cology; the other half was expected to cover about one-
third of the cost of a new medical sciences building.
Under plans set down by the Rutgers University fac-
ulty committee, the new school would closely integrate
medical studies with graduate work in biology and the
life sciences. The school would award a master of medi-
cal sciences degree, and students would transfer to
other institutions for the clinical studies needed to
complete the medical degree. The new school would
heavily emphasize research and would weave the social
sciences and the humanities into its two-year course
of study.
In October 1962, DeWitt Stetten, Jr., M.D., Ph..D„ was
named dean of the medical school. Dr. Stetten, an emi-
nent biochemical researcher, proved to be the school’s
master builder, rapidly launching planning and
fundraising efforts. He also succeeded in recruiting a
small but distinguished faculty, and by 1964, though
it yet had no students or buildings, the school had an
active research program, based in university and in-
dustrial facilities.
In December 1963, an affiliation agreement we
signed between the school and Middlesex General Ho;
pital, to provide for the limited clinical exposure whic
would be required in the basic science program. E
mid- 1964, plans for a $16 million medical science corr
plex had been approved by the University’s board o
governors, and the inaugural class was slated to begi
studies in 1966.
THE FIRST CONFLICT: 1965
The Piscataway school’s smooth progress, eagerly n
ported in the state’s press and hailed by physician;
educators, and politicians was interrupted in the fa
of 1964 when the question arose of a state takeove
of the Seton Hall College of Medicine and Dentistrj
The proposal sparked a clash that was to divide th
state.
Although developing as one of the strongest youn
academic institutions in the nation, Seton Hall Colleg
of Medicine and Dentistry was faltering without th
benefit of public support. In 1964, with a total debt o
more than $7 million, the Archdiocese of Newark peti
tioned the state of New Jersey to take over operation:
of the medical and dental school.
While the decision to continue the school under pub
lie support may seem logical in view of the state’:
growing need, the transition did not come easily. 1
fact-finding committee appointed by Governor Riehan
J. Hughes and chaired by George F. Smith found re
sistance to the proposal, particularly from the school'::
nearest kin, the Rutgers Medical School.
The Seton Hall complex was urban-based, having
operated for ten years from the Jersey City Medica
Center, with affiliations for clinical training in severa
other North Jersey hospitals. And while the school die
have a considerable research program, its curriculum
was oriented primarily toward the clinical practice o
medicine.
Dr. Stetten, however, was a research-oriented pro
fessional. Although he held a variety of prestigious
teaching and research posts, he had not practicec
clinical medicine in a quarter of a century. In all of his
public statements, he had stressed the development ol
curriculum with a similar leaning. In a special article
for the Vineland Times Journal in 1963, he wrote
“Our school, like every other two-year school of recent
planning, will be rich in research orientation. Oppor-
tunities will be presented not only to secure basic sci-
ence medical training but also training toward the
Ph.D. degree in the basic biological sciences including!
biochemistiy, physiology, and microbiology.”
The state acquisition of Seton Hall was viewed by
Rutgers as a threat to its program, both financially and,
philosophically. State support of a second school would
mean that limited tax dollars would have to be split.
And the two institutions would be in competition forj
the same federal and private grant support, particu-
larly if the other school were to be relocated and a new:
campus built for it.
It also was feared that any relationship, however
remote, between the developing school and an estab-
lished, clinical-oriented, community-based program
would endanger the educational goals laid out for the
new school. On this point, the Rutgers administration
792
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
came into direct conflict with the Medical Society of
New Jersey and with many of the state’s political and
community leaders, who felt that New Jersey needed
medical practitioners, and not scientists.
Professionals predicted that a research-oriented
Rutgers Medical School would “turn into a monolithic,
unyieldingly conservative institution,” while lay
leaders took exception to the abandonment of com-
munity hospitals and public health in favor of the
laboratory.
The conflict was resolved, for the time being, by Gov-
ernor Hughes, who wanted both medical schools for
the state. He supported a pair of bills, one allocating
$4 million for the Seton Hall takeover and a second
committing $6 million to the Rutgers program. The
schools were to operate separately, although it was
suggested that in five years the two schools might be
merged, probably under Rutgers University auspices.
Rutgers also was urged to direct its planning toward
a four-year program.
rHE FOCUS SHIFTS: 1965 TO 1970
During the next five years, the two institutions con-
inued to develop their programs separately. At
Rutgers University Medical School, the progress was
smooth and well ordered. In September 1966, a pilot
:lass of 16 students entered the new school. Until per-
manent facilities could be constructed, the program
.vas housed in facilities borrowed from the science
iepartments at Rutgers University. A year later, in No-
vember 1967, the cornerstone was laid for the $16
million medical science building. By now, plans in-
cluded a psychiatric institute and a 450-bed university
rospital. Class size would remain at 16 until the new
building could be completed in 1969.
The Jersey City school, renamed the New Jersey Col-
ege of Medicine and Dentistry (NJCMD) was strug-
gling for its veiy survival. The new public institution
rad to reverse the probationary accreditation status
eft behind by Seton Hall, and to build a strong full-
time faculty, since a large percentage of its professional
staff, hired under Seton Hall auspices, had been part-
:ime and volunteer clinicians.
In addition, it soon became apparent that the school
vould have to be relocated. The College’s trustees de-
ermined that the cost of rehabilitating the Jersey City
vledical Center would be nearly as great as that of
constructing a new complex. Also, the political situ-
ation in Jersey City had made the College’s position
intenable, with local politicians attempting to control
he academic program and fill key faculty positions.
A site selection committee was formed, composed of
medical educators from throughout the nation, in
rrder to choose the best possible location for the new
campus. At the same time, however, a massive cam-
paign was launched by the city of Newark to attract
he medical school, gamering support from the local
press and the community’s social and health care
Agencies.
The setting into which Newark invited the new
.chool was a forbidding one. Ely the early 1960s, the
city was a tinderbox waiting for a spark. The most
iesperate set of social, economic, and political prob-
ems ever seen in the United States had converged
upon the city’s populace. Newark of the 1960s was
beset by crushing poverty. With the second highest
population density in the nation, the city had the fifth
highest rate of unemployment, and was among the
lowest in per capita income and highest in crime rate.
One-third of its housing was classified as substandard,
the highest percentage in any city of comparable size.
The city’s social and financial woes were complicated
further by one of the most serious health pictures in
the country. It had the highest rates of venereal dis-
ease, tuberculosis, and maternal mortality; it had the
seventh highest rate of drug addiction. Death rates due
to accidents, lead poisoning, cancer, and heart disease
also were among the highest in the nation. The city
could offer its population little relief through the pub-
lic health system. When the major public hospital, New-
ark City Hospital (established in 1882), opened its
newest structure in 1954, it already was obsolete, con-
structed from plans for an open-ward facility, which
had been drawn up in the 1930s. EVen though it was
a relatively new facility, the city’s financial difficulties
had caused it to become run-down, overcrowded, and
understaffed.
As early as 1962, Newark’s Mayor Hugh Addonizio
recognized the potential value of a medical school in
easing the city’s problems. He offered Newark City Hos-
pital to any medical school willing to take it over and
run it.
For many in the academic and professional com-
munities, the idea of building a medical school in New-
ark was unthinkable. Although some older educational
institutions had found themselves in depressed areas
during the past decade through the process of urban
decay, none ever deliberately had been built in such
a location. Some medical educators, both on the
school’s faculty and across the nation, felt that a teach-
ing institution had no place in the health care delivery
system, and that educational programs and goals
would be eclipsed by the burden of providing for the
community’s overwhelming health needs. Further-
more, with political pressure mounting in Jersey City,
many hoped to find a free and protected environment
for the troubled school, in which academic programs
would develop without interference or distraction.
In June 1966, the site selection committee strongly
urged that the College accept the offer of a 138-acre
estate of Mrs. M. Hartley Dodge in Madison. Newark,
however, did not allow itself it be written off so easily.
In order to present a better offer than the Madison site,
city officials forwarded a plan to provide 185 acres for
the new campus. According to Donald Malafronte, who
was both director of the Model Cities Program and
administrative assistant to the Mayor, in testimony
before the Governor’s Select Commission on Civil Dis-
turbances, the city knew all along that it could not
deliver such a large parcel of land: “We felt that in the
end they [state officials] would come down in their
demands to 20 to 30 acres in Fairmount, or that in
a battle, we might have to give up some more acreage.
We never felt they would ask for 185. We felt it was a
ploy on their part."
According to Robert R. Cadmus, president of
NJCMD, the College's board of trustees took the offer
at face value. Although they had no need for such a
large tract at present, they felt it was their duty to
/OL. 81— NUMBER 9— SEPTEMBER 1984
793
Figure 1 — UMDNJ-Rutgers Medical School, Piscataway.
provide as much flexibility as possible for future
growth. Neither the trustees nor the school’s adminis-
tration had any idea of what clearing so much land
would mean to the community. By mid- 1967, the Col-
lege agreed to the city’s 185-acre offer.
Black Newark residents, however, had their own view
of the medical school plan. They saw the College as a
greedy invader, taking away their homes and land, and
returning nothing to the community. The black com-
munity had no clear-cut leadership, and as a result,
many different interest groups took advantage of the
community’s anger over the medical school to promote
interest in the city’s other pressing problems. As a
result of issues such as poor housing, unemployment,
inadequate education, and job discrimination, violence
erupted, and Newark rioted. In the eruption, the medi-
cal school nearly was lost. With the perceived danger
from shootings and fires added to their objections,
many faculty members resigned. Students and medical
residents, convinced that they were being used as
pawns in some political game and that their future
careers were being jeopardized, pressed for transfers
to other institutions. The school narrowly missed
being disbanded and its charter relinquished by a vote
of its faculty.
On the other hand, the state of New Jersey and Gov-
ernor Hughes believed that the medical school had a
valid contribution to make in Newark. The situation
warranted new and extraordinary measures, and the
state sat down with the community and negotiated a
site for its medical school.
The ensuing discussions clarified what the com-
munity wanted, what the College planned, and how the
two sets of goals could be unified. The result was the
Newark Agreements of 1968, a social contract which,
perhaps, was unprecedented in the history of medical
education.
Under the terms of this agreement, NJCMD agreed
to accept primary responsibility for health care delivery
in Newark. In the past, the services offered by a medical
school extended only as far as its curricular needs. But
the College agreed to assume the role of “family phy-
sician" to New Jersey’s most medically underserved
population. In education, the College vowed to under-
take special efforts to step up the recruitment of min-
ority students into its own programs, as well as to
develop programs in the allied health professions and
“career-ladder” training for its future employees.
With the signing of the Newark Agreements, tl
medical school’s future was secure. In 1967, it r
located to Newark. On July 1, 1968, Newark City Hosp
tal was acquired by the state for one dollar and r
named the Martland Medical Unit of NJCMD in horn
of the noted Newark pathologist, Harrison Stanfoi
Martland, M.D.
A NEW BEGINNING: 1970
Although the early experience of the medical scho
in Newark had been a painful one, the concepts
social commitment and active participation in healt
care deliveiy brought forward by the controversy mac
a profound impact upon the thinking of New Jersey
decision makers. The state’s health care needs wei
growing more acute throughout the period, and publ
and governmental concern about current and futui
problems was increasing. By 1970, there were mar
who felt that the “radical” concept applied in Newai
should become a statewide model.
On May 4, 1970, in a special message, “Educatio
for Better Medical Care,” Governor William Cahill e:
pressed his concerns for the health professions educ;
tion system to members of the State Senate and Gei
eral Assembly: “New Jersey today needs a re-evaluatio
of policy and a renewed commitment to medical educ;
tion. We have . . . reached a point . . . when the implic;
tions of past decisions can no longer be pushed aside
The Governor and the legislature also felt that it we
too late in terms of the state's health problems to d<
velop traditional medical and dental schools and hop
that they would yield a sufficient increase in pract
tioners. It was felt that since the state was more or les
starting from scratch, there was an opportunity to tak
more positive action with its health professions educ;
tion system.
“New Jersey had the opportunity, and must, for it
own health survival, insist upon that form of medic;1
education which considers the entire medical needs c;
the state,” Governor Cahill said. “While the prime bus
ness of medical educators is obviously education, th
way in which they carry out their mission must b
related to the total community.” The Governor ex
pressed concern, however, regarding the overwhelmin
costs of health professions education, and the mos
reasonable way in which such a burden could be bom
by the state. He feared that two separate institution
competing for the same limited state and federal fund
might not serve the best interests of the state, an
called for legislation to combine the two units unde
a single board of trustees: “A single administrate
entity will be able to advise me on problems of capita
funding for medical education from a statewide per
spective and with expertise.”
Instead of placing the state’s health professions re
sources under Rutgers University aegis as had beei
anticipated in 1966, Governor Cahill moved for th
creation of a freestanding health sciences universit
charged with a dual mission. The College of Medicin
and Dentistry of New Jersey (CMDNJ) was to be re
sponsible for coordination and leadership of healtl
professions education for the state. At the same time
it was to coordinate a system of health services to fil
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
794
entified gaps through its own base facilities as well
|i through cooperation with hospitals and other
ealth resources statewide.
The financial and philosophical implications of this
gislation were too unpalatable for Dr. Stetten. As
ion as the bill became law, he resigned his post at
utgers Medical School, as did a number of other fac-
ty members. The remainder of the CMDNJ-Rutgers
edical School faculty nervously accepted its new
entity, and was to remain ambivalent in its attitude
ward the new institution throughout the early
970s.
The fear in Piscataway was that the overwhelming
feds of its Newark-based counterpart and the huge
instruction planned would relegate its development
a secondary position.
In Newark, meanwhile, the CMDNJ-New Jersey Medi-
il School’s administration, faculty, and student body
gorously supported the Governor's plan and testified
Tore the legislation on behalf of his proposals. It was
It that a statewide system would emphasize academic
aality and would help with the local problems which
id engulfed the Newark campus.
SIDELINES FOR GROWTH: 1970 TO 1979
From its veiy inception, CMDNJ enjoyed a good
easure of willing and enthusiastic support from the
ate— through its governmental leaders, its pro-
ssional communities, and the public at large. A new
■>ard of trustees was appointed by the Governor,
awing capable and dedicated individuals from busi-
es and the professions, headed by John K. Kittredge,
senior vice-president of Prudential Insurance Com-
jny of America With its new optimistic leadership in
!ace, CMDNJ quickly crystallized its priorities for
owth during its first decade. Its efforts would focus
n three major areas simultaneously, each in itself a
aeulean task: construction of a new, $200 million
mpus in Newark, and expansion and improvement
both health care and teaching programs; develop-
ent of the clinical teaching programs at CMDNJ-
jtgers Medical School which would permit it to be-
me a full, four-year program and to augment health
rvices in central New Jersey; and development of a
edical education program in southern New Jersey.
IE GROWTH YEARS: NEWARK
(Throughout the 1970s, the history of CMDNJ New-
ik was one of building, growing, and improving ser-
ies. In 1971, the College broke ground for its $200-
illion campus on a 46-acre site in Newark’s central
jird. The campus, one of the largest building pro-
ams ever undertaken by a health sciences institu-
pn, was dedicated on May 10, 1976, a date which has
ice been observed as Health Education Day in New
rsey.
The campus is the site of four of the University’s six
hools: UMDNJ-New Jersey Medical School, and
vlDNJ-New Jersey Dental School (which are continu-
ions of programs which began under Seton Hall),
VIDNJ-Graduate School of Biomedical Sciences
hich became a school of the College in 1969), and
e UMDNJ-School of Health-Related Professions (es-
blished in 1976).
Figure 2 — UMDNJ-Newark campus.
In health care delivery, the University’s presence has
had a dramatic impact upon Newark. During the first
decade, a coalition of College, state, city, and federal
health programs participated in creating statistics
such as a 50 percent decrease in infant mortality, a
60 percent reduction in tuberculosis deaths, and 50
percent decrease in the cancer death rate, as well as
significant drops due to bronchial pneumonia and
heart disease.
Under the original plans developed in 1968, the
medical school had originally detennined to maintain
Martland as a primary care facility, with a new 272-
bed tertiary care referral hospital to be built on the new
campus to supplement it. On the advice of the com-
munity, and particularly of Newark’s Mayor Kenneth
A. Gibson, the CMDNJ Board of Trustees reconsidered
the plan.
In 1972, the Board voted to have plans for the New-
ark campus redesigned, to incorporate a single, 520-
bed facility. UMDNJ-University Hospital, the final
phase of the Newark construction program, was open-
ed in 1979, further enhancing the University’s ability
to expand the scope of its services and the quality of
care it can offer.
THE GROWTH YEARS: PISCATAWAY
Despite the faculty’s initial misgivings, the newly-
formed CMDNJ moved rapidly to expand its central
New Jersey program.
Before the end of 1970, the opening of the new medi-
cal science building on the Piscataway campus had
allowed expansion of the entering class from 16 to 80
students. In addition, plans were finalized for the 80-
bed Institute of Mental Health Sciences, which would
open in 1972. The Raritan Valley Hospital, Green
Brook, was acquired as a teaching facility, allowing the
development of a full, four-year program. A construc-
tion program at the hospital soon was undertaken to
add an ambulatory care wing, completed in 1973.
For most of the first decade, development at the
Piscataway school centered around the question of a
teaching hospital and full enrollment in the medical
degree program. From the beginning. Raritan Valley
was viewed as a temporary or partial solution, since
it was clear that the 131-bed facility never could ac-
commodate the full entering class, which would level
off at 108 by 1973.
)L. 81— NUMBER 9— SEPTEMBER 1984
795
The acquisition of Raritan Valley did allow, however,
beginnings of a medical degree program. By 1972, the
first third-year class of 32 students was enrolled, allow-
ing for the school to award its first medical degrees in
1974. Third-year enrollment was expanded to 56 the
following year, where it would remain until additional
clinical facilities were acquired. In the meantime,
though, nearly half of each entering class had to leave
the state to complete their degrees.
In 1971, Governor Cahill had promised to build a
325-bed university hospital adjacent to the medical
school in Piscataway. Two years later. Governor Bren-
dan T. Byrne reduced the plan to a 181 -bed tertiary
care center, citing issues such as cost containment, too
many hospital beds in the area, and effective utiliza-
tion of resources. By 1974, architectural plans for this
unit had been developed and the state had issued
bonds to finance its construction. But the bond issue
was not placed for sale, and plans for the hospital
remained in limbo.
The history of UMDNJ
parallels the development of
health professions
education.
The status of the on-eampus hospital remained un-
clarified, and in Januaiy 1976, a special committee
was appointed to consider functional alternatives to a
construction program. The search led eventually to
Middlesex General Hospital, New Brunswick, partly as
a reaffirmation of the College’s commitment to the
state’s underserved urban centers. Negotiations were
opened with the 364-bed facility, resulting in an ex-
panded affiliation agreement, signed on November 23,
1977, which designated it as the school’s core teaching
hospital.
The additional resources and space provided by the
union with the hospital, which recently changed its
name to Middlesex General-University Hospital, have
allowed the third- and fourth-year classes to reach full
size.
THE GROWTH YEARS: SOUTH JERSEY
The idea of a medical education program in
southern New Jersey was first advanced by Governor
Hughes in 1965. As he signed into law the bill by which
the Seton Hall College of Medicine and Dentistry be-
came the state’s second public program in the health
sciences, he predicted that New Jersey would soon
have “a third medical school, this one in southern New
Jersey.”
For the time being, however, the financial pressures
of developing two health sciences campuses proved to
be enough for the state. Seven years passed and
another governor was in office before the concept was
brought forward again. It took seven more years, and
yet another administration, before the first medical
students actually began training in south Jersey.
In 1971, with the beginning of progress already in
evidence at the Newark and Piscataway campuses.
Governor Cahill felt that the time had come for CMDNJ
to explore the question of taking its mission statewic
He directed CMDNJ through the Department of High
Education to develop a feasibility study concerning tl
creation of a medical school in south Jersey. The 1
month investigation included an extensive series
meetings with hospitals, medical and osteopathic c
ganizations, state, local, and federal accrediting age
eies, and other interested parties.
The report, presented to the Governor in May 197
clearly established the need for a medical educatic
program serving the seven-county southern region,
showed that southern New Jersey already had a ph
sieian-to-population ratio considerably lower than tl
state and national average, and that an alarmii
number of those currently in practice were 50 yea
of age and older. It was determined that there wou
be a shortage of at least 100 physicians a year in tl
area by 1980. Other problems related to physieic
supply which were indicated included poor geograph
distribution, decreasing numbers of practitioners
the primary care disciplines, and extensive d
pendenee upon foreign medical graduates. The repo
noted serious health trends developing in south Jersif
and pointed out CMDNJ’s potential ability to help r|
verse the steadily worsening statistics.
The plan advanced by CMDNJ was for a medic
“school without walls.” This term described a progra
which would conduct its clinical education in existir
community hospitals, rather than undertaking coi
struction of a new teaching facility. The concept, whicj
later was employed very successfully by the UMDN.
Rutgers Medical School, was designed to save the sta
money and to strengthen ties with local resources arj
professionals.
The idea of an osteopathic component for the soul
Jersey program was raised from the outset of the plaji
ning process, in the interests of the best utilization
local resources. Two of the largest and best equippel
hospitals in the region were osteopathic hospital
Moreover, a large percentage of the area’s practicir;
physicians, particularly in the primary care specialtie
were D.O.s.
Originally, the College had wished to establish
single program with a unified faculty with option
tracks which would allow students to choose to purse
either the M.D. degree or the D.O. degree. Although
preliminary discussions showed both professions r
sistant to such a plan, CMDNJ believed that it wou!
be appropriate for the College to take a leadership rol
in such an innovative venture, aimed at cementir
relations and enhancing communications between tl
two branches of medicine.
Later, to meet accreditation requirements and II
qualify for federal funds, the program changed fornj
A new school, the CMDNJ-New Jersey School of 0
teopathic Medicine, would be founded, in addition I
an allopathic (M.D.) program, the CMDNJ-South Jersti
Medical Education Program, which would be an e:j
tension of the Newark and Piscataway programs.
In 1975, Governor Brendan Bryne signed the Ne
Jersey legislature’s bill 1540, which directed CMDN
to establish, develop, and operate both osteopathic art
allopathic educational programs in south Jersey t
1976. The College accelerated its efforts to implemer
its dual program.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
796
The allopathic educational program was developed
s a satellite campus of CMDNJ-Rutgers Medical
ehool, in which students would take their first two
ears at the Newark medical school, and then under-
ike the clinical portion of their education in south
ersey hospitals. Cooper Medical Center, Camden, was
lentified as the core teaching hospital for the pro-
ram in 1977, becoming CMDNJ’s first affiliated hos-
ital in south Jersey.
A pilot group of 1 2 students undertook clinical train-
lg at Cooper Medical Center in 1978. The first full
lass of UMDNJ-Rutgers Medical School at Camden
egan studies in Newark in 1981, and entered their
lird-year clinical classes at the Camden facility, now
ailed Cooper Hospital-University Medical Center, in
983. Ultimately, the allopathic program will have 96
aird- and fourth-year students based in Camden,
UMDNJ-School of Osteopathic Medicine became a
)rmal school in December 1976. In order to bring the
ew school into operations as quickly as possible a
lan was devised in which osteopathic students tem-
orarily would receive basic sciences education at
MDNJ-Rutgers Medical School, and take clinical
training at John F. Kennedy Memorial Hospital, Strat-
ford, which became its primary teaching affiliate in
1977. Its first class of D.O. candidates were enrolled in
September 1977, and began clinical training at John
Kennedy Memorial Hospital (now Kennedy Memorial
Hospital/University Medical Center) in September
1979.
CONCLUSION
The achievement of University status in 1981 came
at a turning point in UMDNJ’s development (Figures
1 and 2). During the first decade, the institution vir-
tually had met its enrollment goals and built its cam-
puses, often with limited resources and less-than-per-
fect conditions, it had created innovative solutions to
meet the commitments set upon it by its local com-
munities, the state, and the higher education system.
It had helped to maximize utilization of New Jersey’s
resources bv forming cooperative programs with other
educational facilities, and by affiliating with communi-
ty hospitals to utilize, rather than to duplicate, existing
health care programs.
3L 81 -NUMBER 9— SEPTEMBER 1984
797
The First 40 Years of Osteopathic
Medicine in New Jersey
Robert L. Thompson, ed.d., and Christine Chico, d.o., piscataway*
!
This essay sketches the story of the first 40 years of osteopathic
medicine in New Jersey, from 1900 to 1940. This account
discusses the fight for legal recognition and the right to practice.
Andrew Taylor Still, a frontier
physician and former surgeon
in the Kansas militia during the
Civil War, was the founder of “osteopathy,” a major
reform movement in American medicine. Still dated
his new approach to the treatment of disease to June
22, 1874, when he abandoned traditional medical
practice in favor of osteopathy which rejected the use
of drugs and emphasized the importance of the unim-
paired function of the musculoskeletal system
nourished by healthy vascular and nervous systems.
Osteopathic treatment consisted of the use of
palpatoiy diagnosis to identity the location and extent
of the “osteopathic lesion,” the source of the patient's
complaint, normally followed by manipulative
procedures to treat the affected area or part. Good
nutritional practices, proper rest, and exercise were
prescribed; the use of tobacco and alcohol were dis-
couraged and often forbidden, particularly by Still
himself.3 After an itinerant career in the Kansas-Mis-
souri area. Still settled in Kirksville, Missouri, where
he opened his American School of Osteopathy in 1892.
The first course of study was only 9 months long.4 In
1894, the state chartered his school which authorized
Still to award a professional degree. Although the
School undoubtedly was permitted to confer the M.D.
degree. Still chose "Diplomate in Osteopathy" which
later was changed to “Doctor of Osteopathy;” the D.O.
degree conferred to this day. Still's original school and
imitations which sprang up immediately had no for
mal educational requirements for entrance, a situatioi
which was to cause significant difficulty for the D.O.’
in their attempts to obtain legal and professional rec
ognition including those D.O.'s in New Jersey. By 190C
the curriculum had expanded to two years and 11
months, by mandate of the Associated Colleges of Os1
teopathy and to a compulsory three years and 2'
months program in 1904 by direction of the Americal
Osteopathic Association, founded in 1901.1
According to anecdotal reports, osteopaths firs!
practiced in New Jersey in 1897 to 1898. It is no|
surprising that the first published response to th<
arrival of these new drugless practitioners appeared ir
the Transactions of the Medical Society of New Jersey!
and The Journal , MSNJ. In the reports for the distric!
societies, E.L.B. Godfrey, M.D., of Camden, presented a
warning in 1899 entitled "Osteopathy" which he caller
‘The latest of these fraudulent systems to attain th<!
proportions of a popular fad ... in comparison witl
which the other ‘pathies' shine as radiant stars.”5 Dr
Godfrey further declared that the claims that os
teopathy did not come under the provisions of th<|
Medical Practice Act of 1890 were false. The 1899 re
j
*Dr. Thompson is Associate Dean for Student Affairs am
Admissions and Adjunct Associate Professor, Osteopathi
Sciences, UMDNJ-School of Osteopathic Medicine;
Piscataway; and Dr. Chico is an Intern, Dallas Memorial Hos
pital, Texas.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSET
798
ort of the State Board of Medical Examiners also
oted the situation: “Section IV. The Present Medical
aw. There are but few medical graduates of reputable
ledical colleges who attempt to evade the law. More
ifficulty is experienced with fraudulent practitioners
Iho practice medicine in violation of the law while
aiming technical exemption from its provisions, the
hief of whom are Christian Scientists and os-
xipaths." In spite of this hostile professional climate,
le D.O.’s soon let it be known that they intended to
smain.
In the first of two articles, Hariy Linden Chiles, D.O.,
f Essex County, recalled that "a dozen osteopaths,
ractieally all of the recognized osteopaths in the
tates" met in Newark on October 17, 1901, and or-
anized the New Jersey Osteopathic Society (NJOS).7
i November 1902, the members of NJOS convened in
renton to legally establish their group; the articles of
icorporation for the Society are dated April 18, 1903.
he present name of the organization. New Jersey As-
oeiation of Osteopathic Physicians and Surgeons
4JAOPS) was adopted on May 8, 1948. As Chiles re-
orted: "The organization of the State Society followed
y its incorporation seemed to be accepted by the
ledical organization [The Medical Society of New Jer-
ey] as notice that the osteopaths intended to stay and
iroaden as a profession.”7 On December 6, 1902, the
lembers of NJOS met in Newark to consider the first
f many bills to come which were presented to the
?gislature to provide for the licensing of osteopaths
nd the establishment of a separate board of os-
eopathic examiners to oversee the profession.7
HE FIRST LICENSING ACT— 1913
In 1905, a bill proposed by the newly organized os-
eopaths providing for a separate board of osteopathic
xaminers died in committee hearings. A substitute
•ill offered by the Medical Society placing the D.O.’s
mder the State Board of Medical Examiners with os-
eopathic representation similarly failed.
During the administration of Governor J. Franklin
ort in 1910, the medical community proposed an
mendment to the Medical Practice Act raising
preliminary educational requirements for physicians
I'hich would have excluded most osteopaths then in
practice from qualifying for licensure under any subse-
|uent legislation.7 During a public hearing on the bill,
lovemor Fort had an acrimonious exchange with Dr.
rnther Halsey representing the Medical Society over
he Governor’s campaign promises to the medical pro-
sssion to support high educational standards for
physicians. The Governor called Dr. Halsey a “liar” and
he incident was reported by the press. Governor Fort
etoed the bill which had passed both houses of the
“gislature. At their Annual Meeting a few weeks later,
he Medical Society recorded “His actions have re-
ulted in lowering the standards of preliminary educa-
ional requirements in New Jersey and the consequent
dss of reciprocity between our state and the state ol
Jew York.”8 The Governor later invited several New
lersey D.O.’s to be among the medical guests at a re-
eption at the Summer White House in Long Branch
or General Leonard Wood: Chiles noted that this ac-
ion was a significant mark of recognition for the pro-
ession.7
In 1913, the members of NJOS. 120 strong, were
unable to successfully oppose a bill to amend the Medi-
cal Practice Act similar to the proposed measures of
1905 which placed the authority to license osteopaths
under the State Board of Medical Examiners. An in-
fluential group of “irregular" osteopaths, those D.O.’s
who had graduated from an osteopathic school unap-
proved by the AOA, who were not members of NJOS
sided with members of the Medical Society in support
of a joint M.D.-D.O. board of examiners. At a meeting
of NJOS on March 19, 1913, the members agreed that
it was useless to oppose further the offensive bill which
passed the legislature on April 2, and signed into law.
Dr. D. Webb Cranberry, president of NJOS, was selected
to be the first osteopathic representative on the State
Board of Medical Examiners.7
The Registnj of Osteopathy in the office of the New
Jersey State Board of Medical Examiners, Trenton,
contains the names and the required personal and
educational information about, the first 113 D.O.’s who
presented credentials certifying to their personal at-
tendance and graduation from a regularly organized
school of osteopathy. Each of these D.O.’s was “regis-
tered" on April 12, 1913, and given a license to file with
the clerk of the court in the county where he resided.
Thirty-four percent of this original number were
women. Many of the “irregular” osteopaths presented
credentials to the Board in order to be registered. Dr.
Cranberry recommended rejection of most of these ap-
plicants. His recommendations were sustained by the
Board but the disappointed “irregulars” sued the
Board to obtain their licenses. The compromise solu-
tion required the applicants to take additional instruc-
tion, The process of litigation, however, brought em-
barrassing publicity to the D.O.’s concerning the short-
lived New Jersey College of Osteopathy in Passaic
(1906 to 1910) where diplomas were issued for little
or no attendance.
What did the osteopaths receive in this legislation?
They received a license to practice “osteopathy" which
forbade them from prescribing or administering any
drugs or medications and the performance of any sur-
gery “which required a cutting edge.” They were per-
mitted to practice obstetrics, but were not permitted
to relieve the pain of childbirth with analgesics; they
were authorized to sign birth certificates and death
certificates, but were forbidden to perform any emer-
gency surgery which might have saved a life. In ad-
dition, they were required to observe the same
procedures as M.D.’s in reporting contagious diseases.
According to the new licensing act, D.O.’s would take
the same examinations as M.D. candidates with the
exception of drug therapeutics being examined in-
stead of osteopathic principles and practices. They
were limited by the new law to the use of manipulative
osteopathic treatments although they considered
themselves to be complete physicians. As Heiminski
reported, the first state practice laws which estab-
lished the rights of osteopaths denied them identifi-
cation as complete physicians and served to establish
them instead as practitioners who were legally limited
to the use of manipulative procedures,9 This "status
inconsistency" has confused the public as to the place
of the osteopathic physician in the hierarchy of health
care professionals.1
7OL. 81— NUMBER 9 — SEPTEMBER 1984
799
No account of medical history of this period can omit
a reference to the critical analysis made of medical
education by Abraham Flexner in 1909 to 1910 on
behalf of the Carnegie Foundation for the Advance-
ment of Teaching. He ridiculed the pretensions of the
osteopathic colleges toward any scientific medical
education, but recognized that they were well-run
businesses.10 The osteopathic schools always playing
catch-up ball did not need the Flexner Report to en-
courage them; the years following his report marked
the beginnings of a vigorous curriculum expansion in
both the basic and clinical sciences.
CURRICULUM REFORM AND
EDUCATIONAL STANDARDS
The period between the first osteopathic licensing
act in 1913 and the achievement of unlimited practice
rights in New Jersey in 1935 was marked by two im-
portant developments; the evolution of the curriculum
in the D.O. schools and the impetus to improve the
general educational standards of the profession.1
There was no instruction in drug therapeutics in the
curriculum of the early osteopathic schools. This void
caused difficulties for the D.O. applicant for licensure
in states with a joint M.D.-D.O. board of medical exam-
iners such as New Jersey. Although the D.O.’s were not
examined in materia medica, there were questions
about drug therapeutics on other sections of the exam-
inations. The “lesionists” D.O.’s insisted upon restric-
ting osteopathic practice hence osteopathic instruc-
tion to manipulative procedures and drugless adjuncts
such as diet and exercise. The “broad” osteopaths
wished to be able to employ some of the more common
drugs including analgesics. The American Osteopathic
Association did not agree to permit the inclusion of
pharmacology or drug therapeutics in the curricula of
the osteopathic schools until 1929.
The lack of uniform educational standards for ad-
mission to the osteopathic schools was another major
sticking point whenever D.O.’s pressed for a lib-
eralization of state medical practice arts. The AOA did
not stipulate that the completion of a high school
education was necessary for entrance until 1920. Dur-
ing the 1921 session of the New Jersey legislature, two
bills were introduced concerning the regulation of os-
teopathic medicine. One bill called for the creation of
a new board of examiners to regulate drugless practi-
tioners; the bill failed chiefly because members of the
regular medical establishment were committed to
maintaining the licensing authority for all health pro-
fessionals under the jurisdiction of a composite board
of examiners.11 The more difficult bill proposed much
higher educational standards for osteopaths. The
measure would require all applicants for a license to
have completed private or public high school and one
year of preprofessional education at the college level
before entering an osteopathic school. The bill also
called for an increase to two years of premedical stud-
ies by 1925. In addition, it was proposed that the D.O.
applicant complete a one-year intensive postgraduate
program in surgery at an osteopathic college. A special
examination then was to be required in surgery. The
successful licensee then would be empowered to prac-
tice as an osteopathic physician and surgeon. The fact
that there were no hospitals in New Jersey in which
a D.O. could perform surgery was a significant fact
in the total movement by New Jersey D.O.’s to establi:
their own institutions. After the bill had failed, f
president of NJAOPS suggested that the high i
standards proposed for D.O.'s had nothing to do wi
greater protection for the public, but was in fact a mo
to reduce professional competition." The osteopath
profession in New Jersey as elsewhere continued
gain a public following, but incidents such as the di
missal in February 1928, of Dr. James E. Chastney
Hasbrouck Heights as the local school physician on tl
grounds that he was not qualified by law to sen
exemplified some of the professional discord whir
existed and kept the public confused about the stati
of the osteopath."
The postwar period opened
a new horizon for the
osteopath.
In 1929, the osteopaths again mounted a major carr
paign to gain more favorable practice rights. The NJO
supported Senate 44 which would have required tw
years of premed education and a two-year intemshi
for D.O.’s who wished to practice obstetrics and sui
gery without restriction. This measure died in commit
tee.
Although educational standards were bein
tightened by both D.O. and M.D. schools, the Minutel
of the State Board of Medical Examiners for November
18, 1926, contain instructions to the secretary to writ
to the osteopathic colleges concerning the admission
of students who have not completed high school. B
the end of the 1920s, the osteopathic profession hail
confronted and dealt with the problem of curriculun
reform, particularly the introduction of drug thera
peutics and educational standards had been raised!
The six colleges of osteopathy were graduating on thij
average a total of 350 new D.O.’s annually.1
THE GOAL IS REACHED
The decade of the 1930s did not begin on a felicitomj
note. The Bulletin of NJAOPS for Januaiy 1930, re
ported that one D.O. had been arrested weekly since
Christmas for practicing beyond the limit of the;
license. In a special mailing, NJAOPS warned its mem
bers to avoid writing prescriptions, administering
drugs, or giving irrigations. These embarrassments!
did not concern the osteopaths who scrupulously prac-
ticed “ten-fingered osteopathy” within the law, but
they were symbolic of a basic inconsistency between
the D.O.’s education as a complete physician and the
restrictions of an out-of-date medical practice law. Just
when the profession needed them the most, a particu-
larly talented and dedicated group of leaders emerged
at NJAOPS who combined political astuteness with
organizational skills. From 1932 until the passage of
the new medical practice act in 1935, these leaders
directed an unrelenting campaign to achieve full prac-
tice rights for the profession.
800
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
In September 1932, NJAOPS was ready to begin the
gislative battle again. The members were informed by
r. O. J. Snyder, dean of the Philadelphia College of
[steopathy, at their monthly meeting that if they
mght the “status and dignity of licensed physicians
i a parity with the medical doctor, you must first
•cure legislation that will vest in you like authority
hder the law.”12 On Februaiy 27, 1933, the Senate
ajority Leader Clifford R Powell introduced Senate
26 which included expanded practice rights and an
idependent board of examiners for the D.O.’s. By the
ear’s end no progress had been made because of “per-
mal political ambitions and cliques in Trenton.” In
pbruary 1934, NJAOPS president John T. Atkinson of
ontclair reported that the “medical machine" was
jutting finishing touches on a bill which would greatly
.‘strict the osteopaths then in practice and make it
npossible for new D.O.’s to enter the state. Ely March,
le D.O.’s bill of the previous year was introduced as
enate 73 and the M.D.’s brought in Senate 183. The
ledical bill proposed to deny the use of the titles “Dr.";
Doctor”; “Physician”; and “Surgeon" to all but doctors
f medicine or dentists. Any other practitioner found
|sing the forbidden designations on business cards,
tterheads, or office signs would be punished by a
200 fine for the first offense.12 The bill was so ex-
'aordinarily punitive that it failed.
The last Bulletin of the Association is dated March
935. Chairman English appealed to as many D.O.’s
Ind friends of osteopathy as possible to crowd the halls
f the General Assembly in Trenton when the new
ledical Practice Act came up for a vote. On May 6, a
mch revised bill which was the result of hours of
anferences between the D.O.’s and M.D.’s passed the
ssembly 44 to 1; on May 24 Governor Hoffman signed
le legislation which would admit D.O.’s by examin-
tion for licensure to the unlimited practice of medi-
ine and surgery.12 The bill provided that D.O.’s and
I.D.’s would have to meet the same premedical and
rofessional educational requirements to qualify for a
cense after November 1, 1941; another clause stipu-
ited that no further licenses to practice “osteopathy”
rould be issued after July 1, 1939. On that date an
ra in the history of medicine in New Jersey would
ome to an end.
AFTERMATH
The law specified that osteopaths currently practic-
ing would be required to complete a two-year post-
graduate course in order to qualify for an unlimited
license. At the end of the course they were to be exam-
ined in surgery and medical therapeutics.
With a tremendous struggle finished, NJOS began to
build the Association's membership rolls. In 1936, a
count of D.O.’s in New Jersey showed a total of 319 of
whom 163 belonged to the NJOS. When World War II
arrived. New Jersey D.O.’s like osteopathic physicians
nationwide found themselves disqualified for federal
service because they were not graduates of a “Class A”
medical school. They became by default the health
providers to a large number- of the civilian population
and demonstrated their contribution was more signifi-
cant than might ever have been imagined. Conse-
quently, the postwar period opened up a whole new
horizon for the osteopath which still is being realized
today.
REFERENCES
1. Gevitz N: The D.O.'s: Osteopathic Medicine in America.
Baltimore, MD, The John Hopkins University Press, 1982.
2. Booth ER History oj Osteopathy and Twentieth-Cen-
tury Medical Practice. Cincinnati, OH, The Caxton Press,
1924.
3. Still AT: The Autobiography of Andrew Taylor Still.
Kirksville, MO, 1908, pp. 112-117.
4. Hildreth AG: The Lengthening Shadow of Andrew Tay-
lor Still. Kirksville, MO, 1942, p. 39.
5. Godfrey ELB: Osteopathy. Trans Med Soc NJ. 1899, p.
322.
6. Ninth Annual Report of the State Board of Medical
Examiners, 1899. Trenton, NJ, MaeCrellish and Quigley.
State Printers, 1900.
7. Chiles HL: The Establishment of Osteopathic Practice in
New Jersey, Part I. Bulletin NJ Osteopathic Soc 39:5-6, 1941.
8. Rogers FB, Sayre AR The Healing Art: A History oj the
Medical Society of New Jersey. Trenton, NJ, The Medical
Society of New Jersey, 1966, p. 189.
9. Helminski F: That Peculiar Science: Osteopathic Medi-
cine and the Law. Law Med 32-37, 1984.
10. Flexner A Medical Education in the United States and
Canada: A Report to the Carnegie Foundation for the Ad-
vancement of Teaching. Boston, MA, The Merrymount Press,
1910, pp. 62-67.
11. Newark Evening News, March 5, 1921; October 6,
1921; March 1, 1928; May 24, 1935.
12. The Bulletin, October 1932; March 1934.
rOL. 81— NUMBER 9— SEPTEMBER 1984
801
The History of the
New Jersey Hospital Association
Linda Staab, princeton*
In 1918, hospital executives saw the need for an organization to
promote the concerns of the health care industry and to solve
common problems . Hence, the New Jersey Hospital Association
was bom.
On January 11, 1863, St. Maiy
Hospital, Hoboken, was founded
by four Franciscan Sisters of the
Poor from Germany. In 1864, the same order sent three
additional nuns from Germany to found St. Francis
Hospital, Jersey City. Women from six Protestant
Episcopal churches in Newark in 1865 founded Saint
Barnabas Medical Center, staffed completely by volun-
teers. (Now located in Livingston, Saint Barnabas
Medical Center no longer is associated with a religious
denomination.) By the end of the decade, eight more
hospitals had been established: Jersey City Charity
Hospital (its forerunner was the Pest House, founded
in 1805 and used to quarantine those with infectious
diseases): Saint Michael’s Medical Center, Newark; the
Asylum for Essex County Incurables; the New Jersey
Lunatic Asylum, Trenton; St. Joseph’s Hospital and
Medical Center, Paterson; German Hospital: Hospital of
the Ladies Association; and St. Peter’s Medical Center,
New Brunswick.
This, then, was the genesis of civilian hospital his-
tory in New Jersey, and institutions continued to be
established to provide care within the state.
NEW JERSEY HOSPITAL ASSOCIATION
Ely 1918, seven hospital executives saw the need for
an organization to promote the concerns of the health
care industry and to find solutions to common prob-
lems. The executives met at Newark City Hospital and
established the New Jersey Hospital Associatie
(NJHA). Hospitals represented were Muhlenberg Ho
pital, Plainfield: Elizabeth General Hospital: Hudsc
Tuberculosis Hospital and Sanitarium, Secaucus; Me
ristown Hospital; Paterson General Hospital; Chri
Hospital, Jersey City; and Newark City Hospital.
Following that first gathering in 1918, meetings
the Association were held for several years. Questior
of how hospitals managed their affairs and the sharir
of information on operational issues lay at the base
regular meetings; but, “before the ease of automobi
transportation, it was difficult to attract membe:
from all parts of the state to the meetings (so) . . . tl
Association lay dormant for a period."
THE 1920s AND 1930s
The 1920s were a growing time for the New Jerse
Hospital Association. NJHA now was strong enough 1
host two of the American Hospital Association’s ai
nual conventions in Atlantic City— one in 1926 an
one in 1929. Then, with just 63 days remaining in th
decade, the stock market crash had begun. The D<
pression enshrouded the United States and much (
the world. In the decade that followed, unemploymer
reached 12 million. Congress passed the Social Secu;
ity Act and labor unions won their first major cor
*Ms. Staab is Assistant Director, Public Relations, New Jerse
Hospital Association.
802
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
tracts from the automotive and steel industries. In New
Jersey, efforts were underway to increase access to
hospital care for the middle class and the poor. An
^vent of lasting significance was the establishment in
1932 of the Hospital Service Plan of New Jesey (Blue
Cross). The Service Plan was organized by the cooper-
ative effort of 17 New Jersey hospitals, with the hospi-
tals agreeing to accept flat rate payment of $6 per diem.
Between 1931 and 1936, the New Jersey Emergency
Relief Administration payments exceeded $6 million
for support of general health services, more than $2
million of which went directly to hospitals for the care
of indigent patients.
rHE 1940s
During the 1940s, hospitals continued their battle
:o find ways to provide adequate care for indigent pa-
ients. Following an extensive study, the NJHA Welfare
Committee in 1945 recommended that legal re-
sponsibilities for providing good hospital care for the
ndigent be defined more clearly, that public
luthorities recognize that the indigent were entitled
;o a high standard of care, and that payment to hospi-
:als be commensurate with the services rendered so
hat a hospital’s financial status would not be jeop-
irdized.
In the latter 1940s, returning soldiers flooded the
ration and the wounded crowded hospitals, increasing
:he demand for nurses. A 1948 NJHA survey showed
hat ten hospitals in the state closed a total of 321 beds
lue to the lack of nurses. In response to the shortage,
NJHA began preparing a report on “Recommended
Minimum Standards for Salaries and Personnel Prac-
:ices of Institutional Staff Nurses.” On the national
evel. Congress reacted to the enhanced expectations
rf returning veterans by passing the Hill-Burton Act.
rhe act, created to aid hospital construction and mod-
ernization, provided hospitals with low-interest con-
struction loans in exchange for pledges to absorb a
percentage of charity cases. Most New Jersey hospitals
received grants from this program during the 1950s
and 1960s.
NJHA also was experiencing changes and growth: in
1947, Harold Johnston was hired as the first full-time
executive secretary (now the office of the president). In
addition, NJHA formed the Middle Atlantic Hospital
Conference (forerunner of the present Middle Atlantic
Health Congress) with the New York and Pennsylvania
Hospital Associations.
THE 1950s AND 1960s
In the 1950s, transportation and communication
leaped forward; the urban population began the tran-
sition to the suburban population, reversing the trend
which helped make the expansion of hospital develop-
ment possible in the first half of the century. The cities
developed “inner cities.” Money began to flow to the
suburbs, leaving inner city hospitals to cope with a
high percentage of indigent patients. Additionally, the
hi-tech push into space commenced, adding momen-
tum to the technological advances occurring in hospi-
tals and necessitating additional skills and continuing
education for health care practitioners. Reflecting the
growth, the Hospital Association purchased, for
$18,500, its headquarters building in Trenton, re-
maining there until relocating to Princeton in the
1960s.
NJHA continued to be involved with the concerns of
the nursing profession. During this time, NJHA as-
sisted in revisions to the Nurses Practice Act. The in-
volvement established NJHA as the official consultant
to the Board of Nursing on matters of curriculum for
schools of nursing.
The relationship with another group — unions — also
drew NJHA’s attention. In 1950, when unions at-
tempted to solicit hospital employees, court decisions
held that because hospitals were classified as chari-
table organizations and not as industries, unions had
no legal right to demand collective bargaining. By
1958, however, the situation was changing, and the
Association developed a series of institutes stressing
the positive aspects of labor-management relations. By
1960, NJHA had commissioned landmark studies of
labor relations in hospitals. In 1966 to 1967, in the
landmark Christ Hospital case, the U.S. Supreme
Court declared that New Jersey hospitals were not to
be considered exempt from labor unionization at-
tempts.
—iiw iiiimniii iimiw if iii i i in i 1 1'! ifwwnwiwimwii— nw
In the 1960s ,
reimbursement and
planning became targets for
action by NJHA.
In 1963, Jack Owen took over and was to lead the
Association for 19 years.
The passage of Medicare and Medicaid in the 1960s
mitigated the problem of providing health care for
those unable to pay. But the relief was only partial and
those hospitals with severe indigency problems began
to stagger under the financial burden. Solutions were
still to be found.
Early in 1964, NJHA founded the Hospital Research
and Educational Trust of New Jersey to study ways in
which “men, money, and materials can be more effec-
tively used in the hospital operation, and to study new
concepts in health care.” The next year saw the estab-
lishment of the NJHA Insurance Fund, a group in-
surance program for hospital employees.
Two complicated issues— reimbursement and plan-
ning— became targets for action by hospitals in the
Garden State. A voluntary health planning mechanism
was developed in the mid-1960s under the aegis of
NJHA. It became the independent, nonprofit Health
Facilities Planning Council, functioning under a Board
of Trustees with regional committees representing
various sections of the state.
Local planning committees were established in each
section to review hospital projects and provide rec-
ommendations to a statewide board.
As for reimbursement, in 1968, 15 hospitals began
a voluntary budget review process, subjecting their
budgets to the Hospital Research and Educational
Trust. This was just the beginning of a long and veiy
complex trail.
VOL. 81— NUMBER 9— SEPTEMBER 1984
803
THE 1970s
During (he 1970s, a federal health planning program
supplanted New Jersey’s voluntary planning program.
Under the federal program, New Jersey was divided
into regional planning areas in which five Health Sys-
tems Agencies presently function. The governing
boards of these agencies are composed of volunteers
and include at least 51 percent consumer represen-
tation.
In 1971, the state legislature enacted the Health Fa-
cilities Planning Act which created the Health Care
Administration Board (HCAB), and eertificate-of-need
controls on hospital capital projects. The Hospital As-
sociation assisted hospitals in applying for certificates
of need and represented the industry at meetings of
the HCAB.
In 1975, the Department of Health implemented a
new payment system, the Standard Hospital Account-
ing and Rate Evaluation System (SHARE). This system
used a uniform cost-reporting system and determined
rates by comparing similar hospitals.
The following year, in response to a crisis in avail-
ability of malpractice insurance and to soaring
premiums, the Health Care Insurance Exchange was
formed. It was the first licensed, hospital-owned in-
surance reciprocal in the United States.
In 1978, with inflation at a fever pitch, the state
legislature enacted S-446, a law which set the stage for
a statewide prospective payment system. This law
created the Hospital Ratesetting Commission with the
power to approve rates for all payers of hospital ser-
vices. It altered the manner in which these rates are
approved or adjusted and made major changes in the
Health Care Facilities Act of 1971. By extending the
state’s ratesetting power to all payers, hospital rates
were controlled for the privately insured persons and
the uninsured as well. The law enabled the state to
apply for a federal waiver to set rates for Medicare
patients and provided that hospital rates be based on
defined “financial elements” which guaranteed that
basic costs, such as those for indigent care and bad
debts, would be covered. At last there was some real
relief promised for hospitals burdened with a dis-
proportionate share of indigent patients.
NJHA devoted considerable effort to help hospitals
implement the new reimbursement system, which was
based on Diagnosis Related Groups (DRGs), developing
management reports, and a comprehensive data base.
The Association also worked vigorously to achieve
modifications and refinements as needed.
Another issue which began to receive attention from
the state and federal governments was licensure of
health care personnel. By 1970, over 800 occupations
and professions were licensed, and NJHA had writt i
“Guidelines for Drafting and/or Evaluating Proposl
Legislation for the Licensing of Health Personnel,” a
ing for a re-evaluation of the licensing system. T
state and federal governments formed study groups
1971 and both referred to the NJHA position papers*
licensure. The matter of credentialing continued to
debated into the next decade.
With the passing years, health care technology t
came more complicated and more encompassing, ai
the issues became even more complex. Professo
health care providers, clergy, and ordinary citizens c
bated the definition of life and of death, the ethics ai
economics of access to hi-tech equipment and pr
eedures, and the ethics and economics regarding tl
use of life-support equipment and when to discontim
its use. The Karen Quinlan case forced a hard decisk
in the New Jersey courts. In 1976, the State Supren
Court ruled that patients may be allowed to die if the
is “no reasonable possibility of the patient ever emer
ing from a comatose condition to a cognitive, sapiei
state,” providing that the patient’s prognosis is coi
firmed by a prognosis or similar type of committe
Representatives from state government and pr
fessional groups later agreed with the court that tl
prognosis for the patient’s recovery should be the bas
for such decisions. Voluntary guidelines were d
veloped and subsequently forwarded to New Jersey
hospitals to assist them in establishing prognos
committees to confirm the attending doctor’s opinio
that the patient’s condition is hopeless. The prognos
committee of six or seven physicians was to be coi
vened at the written request of the patient’s family (
guardian.
In 1977, NJHA moved into its modem facility i
Princeton.
THE PRESENT DECADE
In 1982, Louis P. Scibetta, was appointed presiden
of the Association. The Association develops position
and initiates programs on behalf of hospitals througJi
a structure of councils and committees, composed c
hospital representatives, which report to the NJLL
Board of Trustees. The councils are: Council on AuX
iliaries; Council on Finance; Council on Govemmen:
Relations: Council on Hospital Governance; Council oi
Management Practices; Council on Planning; an<
Council on Professional Practice.
Today, hospitals in New Jersey provide quality car'1
in more than 100 communities. Employing sorb
94,000 workers and spending more than $3 billioi
annually in the state, hospitals have become one of tb
state’s largest industries.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
804
Tew Jersey State
Turses* Association
ANET L. FlCKEISSEN, R.N., LANOKA HARBOR*
The New Jersey State Nurses* Association has a history of striving
o elevate health care standards and services for all people in our
itate. And today , the Associations activities are as complex and
iroad as current nursing practices .
i
,
The New Jersey State Nurses' As-
sociation (NJSNA), the official
voice for professional nursing in
;w Jersey, has a rich history of striving to elevate
?alth care standards and services for all people
irough high standards of nursing practice. During its
3 years, the Association has matured into a force
^fitting the largest group of health care providers. The
ssociation was organized on December 4, 1901, at
ewark City Hospital where 200 graduate nurses
ithered to form an organization which could secure
gistration and advance the young nursing pro-
ssion.
At the turn of the century, nursing was not regu-
ted: untrained nurses competed with graduates of
aining schools. “Residence duty” was the provision
care in the home for 24 hours a day until the patient
^covered. The title “nurse” did not connote a pro-
ssional practitioner; women could be self-proclaimed
urses or have taken correspondence or “short
Durses” and earn the same $25 weekly fee as the
raduate of the finest hospital school of nursing.
Thus, the foremost goal for the the Association was
) have a state registration law enacted. In April 1903,
le New Jersey bill to license nurses became the sec-
ad such law in the nation. This simple registration
iw granted licenses to graduates of two-year hospital
aining programs. In 1912, the bill was strengthened
hen Governor Woodrow Wilson signed into effect the
law creating the Board of Nurse Examiners, giving
nurses an autonomous regulatory board. Raising
educational standards, defining the practice of nurs-
ing, and licensing nurses continue to be functions of
the Board of Nursing.
The early decades of the Association were a time of
tremendous growth in both the number of nurses and
the scope of nursing in New Jersey. An Association
investigation during 1910 focused on county alms-
houses, revealing sordid conditions: The Essex County
Almshouse in Newark housed 240 “inmates" with all
types of illnesses; the inmates cared for each other,
summoning a physician only to pronounce death. The
Nurses’ Association formed an Almshouse Committee
to rectify such squalor through improved sanitation
and isolation of those with communicable diseases. A
Committee on Establishing Nurses in Towns in New
Jersey then was created to improve public health con-
ditions; this group was the forerunner of community
health nurses. In 1907, New Jersey's first visiting nurs-
es were placed in Trenton and Camden as a result of
the Committee’s work. These early visiting nurses
taught venereal prophylaxis and infant welfare and
campaigned to eliminate public drinking cups.
During the Depression, the young Association dealt
with momentous changes in nursing practice. Few
*Ms. Fickeissen is the History Project Director of the New
Jersey State Nurses' Association.
rOL. 81— NUMBER 9— SEPTEMBER 1984
805
people could afford to hire private duty nurses; the
resultant unemployment among nurses was stagger-
ing. One registry reported that their nurses averaged
only one week of work during 1932. Hospitals em-
ployed few if any of the nurses that they trained, rely-
ing instead on students to staff the wards under little
or no supervision.
The New Jersey State Nurses’ Association responded
to the crisis by promoting the eight-hour day and en-
couraging hospitals to hire graduate nurses to supple-
ment the students or untrained attendants who
provided meager services to patients. The Association
also condemned the proliferation of nursing schools in
hospitals; New Jersey alone had 48 hospital schools by
1933, some without a single full-time nursing instruc-
tor. Through the Board of Nursing, the Association
raised the standards for nursing education by man-
dating a high school diploma raising the passing
scores on the licensing examination, and requiring at
least one full-time nursing instructor in every school.
The nursing glut of the 1930s was replaced by a
critical shortage in the 1940s when the nation went
to war. To meet the increased demand for nurses, the
Association worked to recruit students into nursing
schools and classified nurses as essential or available
for active duty. Nearly 3,000 New Jersey nurses served
in either the Army or Navy Nurse Corps during the war.
To meet the demand for nurses, all 42 of New Jersey’s
nursing schools participated in the Cadet Nurse pro-
gram in which students spent their last six months
of training in either civilian or military hospitals. To
cope with the acute shortages of nurses in civilian
hospitals, guidelines were developed by NJSNA for the
many auxiliary hospital workers such as aides and
volunteers that were needed to supplement the nurs-
ing staff. The Association also established a counseling
sendee to assist the large number of inactive nurse
to return to nursing for the war effort.
After the war, salaries, benefits, and working eor
ditions were slow to improve. The Association pushe
to reduce the 48-hour work week to 40 hours and t
reduce salaries. The Association expended mue
energy from the late 1940s through the 1970s on eec
nomie and general welfare issues for nurses.
Changes in the past three decades have been les
abrupt than those of the Depression and war, but ar
no less revolutionary. With increasing teehnolog;
escalating costs, cost containment, and more acute!
ill patients, come the need for highly educated an
skilled nurses able to give humanistic, eost-effectiv
care. Nurses expanded their roles to include th
provision of primaiy care. Nurse practitioner
prepared for expanded practice with graduate educe
tion and certification in the specialty area NJSNA cor
tributed to the revision of the Nurse Practice Act ii
1974 which presently defines nursing as: diagnosinj
and treating human responses to actual or potentk
physical and emotional health problems, through sue!
services as case finding, health teaching, health cour
seling, and provision of care supportive to or restore
tive of life and well-being.
Legislation directing Blue Shield reimbursement fo
nurses in private practice was passed earlier this yea
Today, the Association’s activities are as eomple
and broad as current nursing practice. Ineorporatin
nursing resource use into hospital rate structures
helping chemically impaired nurses, lobbying for Com
parable Worth legislation, detecting and minimizin
occupational hazards for nurses, promoting nursin,
image, and preserving nursing history are only a fracj
tion of the ongoing activities of the New Jersey Stat!
Nurses’ Association.
806
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
New Jersey Medical
Historiography, 1964-1984
David L. Cowen, m.a., litt. d., rossmoor*
With the growing interest in the history of medicine, the author
updates his bibliography on New Jersey medicine . The study
indicates the many accomplishments in medicine.
i
This issue of The Journal is an
indication of the interest in the
history of medicine and allied
sciences in New Jersey during the last two decades.
There are four factors accounting for this growth: 1)
:he general interest in history engendered first by the
:ercentenary of New Jersey and the bicentennial of the
Jnited States; 2) the increasing interest in the history
of medicine by general historians, social historians,
and historians of science; 3) the establishment of the
Medical History Society of New Jersey, essentially the
accomplishment of Morris H. Saffron, M.D., Ph.D., a
man trained as a physician and a historian: and 4) the
Interest of Arthur Krosnick, M.D., in the history of
(medicine, and his encouragement of the publication
of historical articles in The Journal.
The purpose of this paper is to continue and to
update the “Bibliographic Notes” that were appended
to my Medicine and Health in New Jersey: A History
(Princeton, 1964), written as part of the state’s
tercentenary celebration.
GENERAL MEDICAL HISTORY
My 1964 publication, the first full-scale history of
medicine of New Jersey — Stephen Wickes’s History of
Medicine in New Jersey (Newark, 1879) stopped at
1800 — soon was followed by the more detailed, il
lustrated, and exemplary. The Healing Art: A History
of the Medical Society of New Jersey (Trenton, 1966)
by Dr. Fred B. Rogers and A Reasoner Sayre. Although
issued in celebration of the bicentennial of the Medical
Society of New Jersey, the book is a comprehensive
account of the history of medicine in the state: the
history of the Society is given within the compass of
this general history.
Dr. Rogers presented a brief essay entitled, "The
Medical Society of New Jersey Since 1766,” to a na-
tional audience in JAMA (196:645-646, 1966). Morris
Fishbein reciprocated with “An Historical Appraisal:
The Medical Society of New Jersey" (J Med Soc NJ
63:228-236, 1966) which, although rather general, did
make reference to the New Jersey experience. Dr. Saf-
fron, in his "New Jersey or Massachusetts,” (JAMA
245:2031-2032, 1981; J Med Soc NJ 79:758-759, 1982)
probably has laid to rest any question of the priority
of the Medical Society of New Jersey.
Studies of other professional groups have included
Samuel Berg’s “The Essex County Pathological and
Anatomical Society: A Belated Obituary” (J Med Soc NJ
66:479-480, 1969) in which the closing of the Society
in 1967 is recounted: Dr. Saffron’s "Academy of Medi-
cine of New Jersey — A Brief Histoiy" (Bull NJ Acad Sci
9:5-15, 1964); and Herbert E. Spiegel’s "History of the
New Jersey Section. AACC” (Clin Chem 23, No. 2. Pt.
1:295-296, 1977).
*Dr. Cowen is Professor Emeritus, History. Rutgers Univer-
sity.
VOL. 81— NUMBER 9— SEPTEMBER 1984
807
A number of other articles of interest to the general
history of medicine are to be found in the periodical
literature. These include Peter Guthorn’s “Calling Dr.
Hubbard: Two Hundred Years of New Jersey Medicine”
(J Med Soc NJ 61:419-421, 1964) which covers the
early histoiy of the State Society and describes the
medical practices of the Jacobus Hubbards, father and
son: Dr. Saffron has described “A Medical Diploma of
1820" (J Med Soe NJ 69:684-686, 1972), in which he
presents biographical sketches of the signer, Lewis
Condiet, and the recipient, William Pierson; Saffron
also offered “Remarks on New Jersey’s Contribution to
Medicine" (J Med Soc NJ 73:14-15, 1976) in which he
briefly recounted the achievements of nine New Jersey
physicians: David L. Cowen, Louis D. King, and
Nicholas G. Lordi have described the prescribing prac-
tices of several Burlington physicians in their “Nine-
teenth Century Drug Therapy: Computer Analysis of
the 1854 Prescription Files of a Burlington Pharmacy"
(J Med Soc NJ 78:758-761, 1981).
THE REVOLUTION
The New Jersey Historical Society mounted an
exhibit on New Jersey medicine in the Revolution. The
catalogue of the exhibit, and two historical essays, have
been published under the title of the exhibit: New
Jersey Medicine in the Revolutionary Era, 1 763-1 783
(Newark, 1976). The two essays were: “Medical Back-
ground of the American Revolution" by Fred Rogers
(pp. 7-8) and Dr. Saffron’s major address delivered at
the opening of the exhibit on "Medical Men and Events
in Revolutionary New Jersey" (pp. 9-16).
Richard Torres-Reye has given a careful,
documented account of the medical situation at Mor-
ristown in his Morristown National Park, 1779-1780
Encampment A Study of Medical Services (Washing-
ton, 1971). Fred Rogers has written on “The Old Bar-
racks at Trenton: Military Hospital of the Revolution”
(J Med Soc NJ 73:1 1-13, 1976) in which he pays special
attention to William Shippen. Dr. Saffron has written
on the “Medical Aspects of the Middlebrook Encamp-
ment (J Med Soc NJ 76:376-378, 1979).
Fred Rogers’s biographical sketch of “Dr. William
Bryant (1730-1786) Physician and Antiquary” ( Acad
Med NJ Bull 16, No. 4:18-25, 1970) tells the story of
a loyalist physician. Rudolf E. Trice has written a bio-
graphical memoir of “Hugh Mercer: Physician Hero of
the American Revolution" (Virginia Med 108:104-106,
1981 ), but it makes little reference to Mercer as a phys-
ician.
My booklet. Medicine in Revolutionary New Jersey,
(Trenton, 1975) is a study of the whole Revolutionary
scene.
Dr. Saffron’s work centering on John Cochran is by
far the most significant on the period. His articles
include, “John Cochran (1730-1807): Director General
of the Hospital of the United States” ( Trans Stud Coll
Phys Phila 43:379-387, 1976); “Dr. John Cochran, the
New Jersey Years” (Acad Med NJ Bull 16, No. 4:26-34,
1970): “Confrontation in New Jersey: The Hospital Ver-
sus the Line” (J Med Soc NJ 73: 108 1-1087, 1976); “The
Tilton Affair" (JAMA 236:67-72, 1976). Dr. Saffron’s
studies culminated with Surgeon to Washington: Dr.
John Cochran 1 730-1807 (New York, 1977) which con-
tains a biography of Cochran and reprints his letter
books.
Finally, reference must be made to Whitfield J. Bel
Jr.'s John Morgan: Continental Doctor (Philadelphia
1965) which does mention, though scantily, the New
Jersey scene.
COUNTY AND LOCAL HISTORY
Dr. Michael A. Nevins has written about Bergen
County: his book. Early Physicians of Northeastern
Bergen County (Spring Valley, 1979), contains many
interesting photographs and illustrations, describing
19th and early 20th century medical practice in that
part of the county. Nevins also wrote "Bergen County’s
Poet-Physicians” (J Med Soc NJ 77:831-833, 1980) in
which he describes the work of Drs. English, Cone,
Williams, and Rosner. With Stewart F. Alexander,
Nevins authored “Home Care Delivery in Bergen Coun-
ty in the 19th Century” (J Med Soc NJ 80:283-287,
1983) based on the records of Dr. Henry C. Neer.
Another work on the local level is that by Norman
Reitman, “Medicine and Medical Care in New Bruns-
wick,” in RH. Patt’s, The Tercentennial Lectures, New
Brunswick. N.J. (New Brunswick, 1982).
INDIAN AND FOLK MEDICINE
Clinton Weslager, in Magic Medicine Among the In-
dians (Somerset, 1973) devotes a chapter to “New Jer-
sey ‘Sand Hill Indian’ Remedies.” Susan Hamburger
wrote on “Medicine of the Leni Lenape Indians of New
Jersey” (Discovery [University College, Rutgers Univer-
sity), 25-33, 1975).
A booklet describing the 1979 exhibition at the New-
ark Museum, Green Magic: Useful Wild Plants of New
Jersey (Newark, 1979), lists and illustrates 41 plants
and gives the medicinal as well as other uses for them.
David S. Cohen has paid some attention to folk medi-
cine; his The Ramapo Mountain People (New Bruns-
wick, 1974) contains an appendix on “Herb Cures and
Folk Remedies,” and The Folklore and Folklife of New
Jersey (New Brunswick, 1983) has a chapter on medi-
cal folklore.
The reprinting of the Early Recollections and Life
of Dr. James Still, (1970), first published in 1877, re-
counts the life and career of a self-educated black “doc- |
tor” who became known as the “Doctor of the Pines.”
SURGERY
The only study of the histoiy of surgery is Henry H.
Kessler's, “The Evolution of Orthopedic Surgery and
Rehabilitation in New Jersey” (Acad Med NJ Bull
13:94-104, 1967).
EDUCATION
The only study related to the history of medical
education is my booklet. Medical Education The
Queens-Rutgers Experience 1792-1836 (New Bruns- i
wick, 1966).
PUBLIC HEALTH AND EPIDEMIOLOGY
Two studies dealing with public health in the col-
onial period are: Lany R Gerlach’s “Smallpox Inocu-
lation in Colonial New Jersey: A Contemporary Ac- j
count" (J Rutgers U Lib 31:21-28, 1967), an annotated
description of inoculation methods from the Hen-
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
808
irickson Family Papers (1753-1787); and William J.
3nape and Edward L. Wolfe’s “The Studies of Yellow
“ever by Noah Webster and John Conrad Otto at Red
Sank, New Jersey" (Bull Gloucester Co HistSoc 19, No.
1:25-30. 1984).
Fred Rogers provided a short review in “Medicine
ind Public Health in New Jersey” (J Med Soc NJ
37:541-543, 1970). Stuart Galishoff provided major
contributions; his Safeguarding the Public Health
Newark 1895-1918 is the only book on the histoiy of
Dublic health in New Jersey. Galishoff also wrote: “New-
ark and the Great Influenza Pandemic of 1918” ( Bull
Hist Med 43:246-258, 1969); “The Passaic Valley
Trunk Sewer" (NJ Hist 88:197-214, 1970); “Cholera in
Newark, New Jersey” (J Hist Med All Sci 25:438-448,
1970); and "Newark and the Great Polio Epidemic of
1916” (NJ Hist 94:101-1 1 1, 1976).
The career of Hemy L. Coit of Newark is told in
Vlanfred J. Waserman’s thorough study: “Henry L. Coit
and the Certified Milk Movement in the Development
af Modem Pediatrics” (Bull Hist Med 46:359-390,
1972).
“Ezra Hunt Mundy — Physician, Writer, Human-
itarian” (J Med Soc NJ 78:381-385, 1981) by Samuel
Ale witz is a study of the leading figure in New Jersey’s
Dublic health movement.
Samuel Berg, in Harrison Stanford Martland, M.D.:
The Story of a Physician, a Hospital and an Era (New
7ork, 1978) covers Dr. Martland’s work on radium in-
toxication. The major work has been done by William
D. Sharpe: “Harrison S. Martland and the New Jersey
Radium Dial Painters" (Acad Med NJ Bull 16:55-62,
1970); “Chronic Radium Intoxication: Clinical and
[Autopsy Findings on Long-Term New Jersey
Survivors” (EnvirRes 8:243-283, 1974); and “The New
Jersey Radium Dial Painters: A Classic in Occupa-
tional Carcinogenesis” (Bull Med Hist 52:560-570,
1978).
Two other papers with relevance to the public health
are William D. Sharpe’s “Autopsies at Newark City Hos-
pital, 1908-1911” (J Med Soc NJ 81:53-62, 1984) and
Allen N. Koplin’s “Anti-smoking Legislation: The New
Jersey Experience” (J Pub Hlth Pol 2:247-255, 1981).
MENTAL HEALTH
The only work of substance with a New Jersey orien-
tation on mental health is Frederick M. Herrmann’s
Dorothea L. Dix and the Politics of Institutional Re-
form (Trenton, 1981).
THE RH FACTOR
One of the significant developments in medical sci-
ence was the work done on the Rh factor at Newark
Beth Israel Hospital by Philip Levine as described in
Camp’s “Forensic Serology in the United States” ( Amer
J Forerts Med Pathol 1:47-55, 1980). Another article
on the subject is AS. Wiener’s “Karl Landsteiner, M.D.:
Histoiy of the Rh-Hr Blood Group System” (NYS J Med
69:2915-2935, 1969) and AG. Erskine and AS. Wiener,
The Principles and Practice of Blood Grouping (St.
Louis, 1973, pp. 320-322).
MICROBIOLOGY
Claude E. Dolman’s concise biography of Theobald
Smith and a bibliography of Smith’s works can be
found in Dictionary of Scientific Biography (New York,
1975 Vol. 12, pp. 480-486). Other of Dolman’s studies
include, “Theobald Smith: Life and Work” (NYS J Med
69:2801-2816, 1969); “Texas Cattle Fever: Tribute to
Theobald Smith" (Clio Medica 4:1-31, 1969);
‘Theobald Smith and his Presidential Address to the
Society of American Bacteriologists” (ASM News,
47:231-235, 1981); and “Theobald Smith (1859-1934),
Pioneer American Microbiologist" (Persp Biol Med
25:417-427, 1982).
The Nobel Prize winning work of Selman Waksman
has produced considerable historical attention: The
Conquest of Tuberculosis (Berkeley, 1964); Micro-
biology in New Jersey (Ann Arbor, 1 965); “The Road
to Streptomycin and Beyond; A Chapter in the History
and Application of Antibiotics” (Rev Soc Mex Hist Nat
30:301-306, 1969); and an account of his role in in-
troducing the word “antibiotics” as a noun in the
Journal of the History of Medicine and Allied Sci-
ences 28:284-286, 1973.
H. Boyd Woodruff, whose autobiographical “A Soil
Microbiologist’s Odyssey” (Ann Rev Microbiol 1981,
1-28) recounts his experiences working with Waksman
and his work in industry with Merck, Sharp and
Dohme. Woodruff also has edited Scientific Contribu-
tions of Selman A Waksman : Selected Articles Pub-
lished in Honor of his 80th Birthday (New Brunswick,
1968).
Julius H. Comroe, Jr. has shown how Waksman’s
interest in soil microbiology developed into an interest
in antibiotics and led to the discovery of streptomycin
in his “Pay Dirt: The Stoiy of Streptomycin Part I: From
Waksman to Waksman” (Amer Rev Respir Dis
117:773-781, 1978).
Finally, the most recent work at the Waksman In-
stitute is described by Hubert A Lechevalier’s The De-
velopment of Applied Microbiology at Rutgers (New
Brunswick, 1982).
DENTISTRY
The March 1970 issue of the Journal of the New
Jersey State Dental Society was devoted to the histoiy
of the Society and of dentistiy.
Ian C. Bennett’s “New Jersey Dental School: History
and Progress” (J NJ Dent Assoc 10:10-11, 1974) de-
scribes the growth of the faculty and students of the
school, the introduction of a three calendar year pro-
gram in 1971, and changes in the curriculum. There
also is a "History of the New Jersey State Dental So-
ciety” in the Bulletin of the Union County Dental So-
ciety (48:8-11, 1968).
PHARMACY AND THE PHARMACEUTICAL
INDUSTRY
I have written The New Jersey Pharmaceutical As-
sociation, 1870-1970 (Trenton, 1970) covering the his-
toiy of the Association, vignettes of the histoiy of phar-
macy in New Jersey, and a biographical roster of the
members of the Association. Louis D. King and I de-
scribed a dosage form introduced by a nationally
known pharmacist from Camden in "George Beringer
and the Fluid Glycerates" (J Am Phann Assoc
6:435-438, 1966). 1 have written on "The Swiss Ameri-
can Pharmaceutical Houses of New Jersey" (Ciba. Hoff-
mann-LaRoche, and Sandoz) in G. Schramm, Neue
VOL. 81— NUMBER 9— SEPTEMBER 1984
809
Beitrage zur Geschichte der Pharmcizie (Zurich,
1978) pp. 37-45. W.H. Helffand, H.B. Woodruff, K.M.H.
Coleman, and D.L. Cowen wrote on "Wartime Indus-
trial Development of Penicillin in the United States,"
The History of Antibiotics: A Symposium (Madison,
1980).
HOSPITALS
Nevins, Berg, Sharpe, and Kessler mention hospitals
in their works. Only two articles devoted entirely to
hospital history have been found: Rosary S.
Gilheaney’s “Early Newark Hospitals" (Proc NJ Hist Soc
83:10-23, 1965) and Thomas J. White’s “Frank Hague
and the Jersey City Medical Center" (Acad Med NJ Bull
16, No. 4:50-53, 1970).
SECTARIAN MEDICINE
H.B. Weiss and H.R Kemble wrote The Great Ameri-
can Water-Cure Craze: A History of Hydropathy in the
United States (Trenton, 1967).
R.L. Numbers wrote “Health Reform on the Dela-
ware” (NJ Hist 92:5-12, 1974) in which the chief
protagonist is Russell Thacher Troll, M.D., who ran the
Eastern Hygeian Home at Florence Heights in Burl-
ington County.
Alfred R Henderson’s “Frederick M. Allen, M.D. and
the Psychiatric [sic, an error for “Physiatric”) Institute
at Morristown. N.J. (1920-1938)” (Acad Med NJ Bull
16, No. 4:40-49, 1970), is another selection.
PHYSICIANS AND PATIENTS
The Journal of the Medical Society of New Jersey
devoted its September 1983 issue to William Carlos
Williams. Other writings about Williams include: Paul
Mariani’s William Carlos Williams: A New World
Naked (New York, 1981); Linda W. Wagner’s “William
Carlos Williams: Poet-Physician of Rutherford” (JAMA
204:15-20, 1968); William B. Ober’s “William Carlos
Williams, M.D. (1883-1963): Physician and Poet” (NYS
J Med 69: 1 084- 1 098, 1969): Nicholas Dewey’s “William
Carlos Williams: The Writer as a Physician” (Acad Med
NJ Bull 16:64-73, 1970); and Robert Coles’s “William
Carlos Williams: A Writing Physician” (JAMA
245:41-42, 1981).
Another New Jersey poet, Walt Whitman, has been
the subject of study: Charles E. Feinberg, “Medical His-
toiy: Walt Whitman and His Doctors” (Arch Intern Med
1 14-834, 1964); Harold B. Bamshaw, “Walt Whitman’s
Physicians in Canada” (Trans Coll Phys Phila
31:227-230, 1964); and "Walt Whitman’s Medical Prob-
lems While in Canada” (Acad Med NJ Bull 16, No.
4:35-39, 1970).
A brief account of “The Medical Van Leer Family of
Pennsylvania and New Jersey” (Trans Stud Coll Phys
Phila 38:44-46, 1970) by Dorothy Lansing is a family
history.
“Edward Wharton Sprague, M.D., FAC.S” by Morris
H. Saffron was the leading article in the Academy oj
Medicine of New Jersey Bulletin (16, No. 4:2-1 1, 1970).
Dr. Morris H. Saffron was the subject of a short
sketch describing his bibliophilic interests in Medico
Economics (57:178-180, 1980) by A.Z. Bain, entitle<
“How to Profit from Medical History — Collect It." j -
ORAL HISTORY
The Medical History Society of New Jersey ha
undertaken a continuing oral history program undt
Stuart Sammis: interviews already have been tape
with Morris H. Saffron: James Hillier, the developer c
the electron microscope; Richard Leedy, Richard Feig<
and Paul Smith, osteopathic physicians who practice
under the old limited practices arrangements; Josep
Gardam, head of the Newark Board of Health for 5'
years: Thomas White, chief of medicine at the Jerse
City Medical Center for many years; Roy A. Bower?
dean emeritus of the Rutgers College of Pharmacy
Lena Edwards; and Arthur Bernstein, noted Newar
cardiologist. All of the transcriptions will be depositei
in the Archives of UMDNJ and at the Academy of Medi
cine of New Jersey.
HISTORIANS
Milton Asbel has written widely on the history o
dentistry and of dental education in the United States
Harry Bloch has written vignettes on interesting facet:
of medical history. Estelle Brodman has written on ora
medical history and other topics. Francis Chinard ha:
written on the American physician, Edward Miller
Vincent Cirillo has written on early views on blooc
fluidity. David L. Cowen continues to write on the his
tory of pharmacy, the materia medica and relatec
topics. Norman Dain has authored three books on tht
history of insanity in the United States. G.L. Geisor
has written on the history of physiology. Gerald Grol
has written on the history of mental illness and menta
institutions in the United States. William H. Helfanc
continues his interest in medical and pharmaceutica
art and graphics. The late Joseph Kler wrote on Louis
Pasteur. Arthur Krosniek has written on the art ol
Banting. Hubert A. Lechevalier and Morris
Solotorovsky have published a history of microbiology
Max M. Novich has written on early sports medicine
William Ober displays an urbane and catholic interesi
in the arts, literature, biography, and medical science
Gary Puckrein has written on colonial medicine and
health. James Reed has written on the history of the
birth control movement in the United States. Fred
Rogers has written on the practitioners of New Eng-
land. Morris H. Saffron has continued his interest in
medieval medicine. William Sharpe has published on
medicine in the Confederacy and on the history of thej
Pennsylvania Hospital. Judith Walkowitz has written
on prostitution in Victorian England. Richard Wedeen
has written on the caricatures of gout.
CONCLUSION
The history of medicine is an ongoing and growing;
discipline in New Jersey. This study indicates not only
what has been accomplished, but perhaps, more im-
portant, what still remains to be done.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
810
HME Calendar
1
Thefollowing is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
I
This list is compiled through the coop-
eration of the Committee on Medical
Education of the Medical Society of New
Jersey, The Academy of Medicine of
New Jersey, the New Jersey Chapter of
the American Academy of Family Phy-
sicians, and the Office of Continuing
Medical Education of the UMDNJ. For
information on accreditation, please
contact the sponsoring organization (s),
indicated by italics— last line of each
item.
ANESTHESIOLOGY
Nov.
20 Dinner Meeting
6-9 P.M.— Ramada Inn, Clark
(NJ State Society of
Anesthesiologists and AMNJ)
CARDIOLOGY
Oct.
17 Calcium and Cardiovascular
Function
1:30-5:30 P.M. — Drew University,
Madison
(Drew University, CIBA-Geigy
Pharmaceutical Division, and
AMNJ)
22 Pharmacological Treatment of
23 Cardiovascular Diseases
8:30 AM.-5: 1 5 P.M. — Resorts
International, Atlantic City
(UMDNJ and AMNJ)
Nov.
15 Cardiology: Newer Cardiac Drags
2-3 P.M. — John E. Runnells
Hospital of Union County
(John E. Runnells Hospital and
AMNJ)
MEDICINE
Oct.
3 Venom Therapy
8-9:30 P.M. — The Manor, West
Orange
(NJ Allergy Society and AMNJ)
3 CDS Prescribing Practices
1:30-2:30 P.M.— Essex County
Hospital Center, Cedar Grove
(AMNJ)
3 Endocrine Conferences
10 3:30-5 P.M. — Rotates between
17 Newark Beth Israel Medical Center,
24 University Hospital, United
31 Hospitals Medical Center, Newark,
and VA Medical Center, East
Orange
(Endocrinology Section, AMNJ)
3 Medical Grand Rounds
10 12 noon- 1 P.M. —Rutgers Medical
17 School, Medical Education Bldg.,
24 New Brunswick
31 (UMDNJ and AMNJ)
3 Medicine Morbidity and Mortality
Conference
8- 9 AM — Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
4 Immuno regulation: Basic
1 1 Concepts and Applications
18 4-6 P.M. —Institute for Medical
25 Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
5 Treatment of Acute Hypertension
19 Headache
9 AM.— St. Francis Medical Center.
Trenton
(St. Francis Medical Center)
9 Common Problems in Diagnosis
and Management of Congenital
Infections
9- 1 0 AM. —Freehold Area Hospital
(AMNJ)
9 The Role of the Computer in
Dermatology
8- 1 0 P.M. — Sehering Corporation,
Kenilworth
(NJ Dermatological Society and
AMNJ)
10 AIDS
9:30-10:30 AM. —Bergen Pines
County Hospital, Paramus
(AMNJ)
10 Diet and Cancer— Albert Siegel
Memorial
2-5 P.M. —Saint Barnabas Medical
Center, Livingston
10
17
31
11
13
17
17
18
23
24
24
27
30
30
Nov.
1
8
15
29
2
VOL. 81— NUMBER 9— SEPTEMBER 1984
(NJ Gastroenterological Society,
American Cancer Society, and
AMNJ)
Nephrotic Syndrome
Leukemias In the Adult
Pulmonary Rehabilitation
1-2:30 P.M. — VA Medical Center,
Bldg. 93, Lyons
(VA Medical Center and AMNJ)
Medical Update: Use of Thyroid
Function Tests
12 noon- 1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
Hyperthermia for Cancer
8:30 A.M. 5 P.M. — Medical Society of
New Jersey, Lawrenceville
(AMNJ)
Dermatological Conference
6- 9 P.M. — Rutgers Community
Health Plan, U.S. Hwy #1 and Rt.
18, New Brunswick
(UMDNJ -Rutgers Medical School)
AIDS
1:30-2:30 P.M.— Trenton
Psychiatric Hospital
(AMNJ)
Rational Approach to Antibiotic
Therapy and New Antibiotics
5-7:30 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
Calcium Metabolism in a Geriatric
Patient
12 noon-1 P.M. — West Jersey
Hospital, Camden
(AMNJ)
Seventh Annual Cancer
Symposium
8-4 P.M. — Executive Motor Lodge,
Mount Laurel
(Burlington County Memorial
Hospital)
Regional CME Meeting, ACP and
NJSIM
9 AM. -4 P.M. — Landmark Inn,
Woodb ridge
(American College of Physicians
(New Jersey) and New Jersey
Society of Internal Medicine)
Basic and Practical EKG Course
8:30 A M. -6 P.M. —Sheraton Heights
Hotel, Hasbrouck Heights
(Palisades General Hospital and
AMNJ)
AIDS in Children
7- 9 P.M. — Englewood Hospital
Learning Center, Englewood
(Englewood Hospital and AMNJ)
Basal Cell Skin Conference
9 A.M. — Office of Dr. Warshaw, 519
East Broad St., Westfield
Immunoregulation: Basic
Concepts and Applications
4-6 P.M. — Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
AIDS
1 2 noon 1 P.M. — Freehold Area
Hospital
(AMNJ)
81 1
THE ACADEMY OF MEDICINE OF NEW JERSEY
presents
a symposium on
HYPERTHERMIA FOR CANCER
Saturday, October 13, 1984
8:30 a. m. -3:00 p.m.
at
MSNJ Headquarters, Lawrencevitle, N.J.
For further information contact:
of New Jersey
EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
Two Princess Road
Lawrenceville, NJ 08648
(609) 896-1717
The Academy of Medicine of New Jersey, Physicians for Social
Responsibility, Northern New Jersey Chapter, Department of
Preventive Medicine and Community Health, UMDNJ-New
Jersey Medical School present
a symposium on
POTENTIAL HUMAN AND ECOLOGICAL
DISASTERS
Saturday, October 20, 1984
9:00 p.m. -3:00 p.m. at
For further information contact:
Town & Campus Restaurant
West Orange, New Jersey
of New Jersey
EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
Two Princess Road
Lawrenceville, NJ 08648
(609) 896-1717
The Academy of Medicine of New Jersey
Association for Hospital Medical Education ol
New Jersey
The Medical Society of New Jersey
presents
a workshop on
0
CME ESSENTIALS
Wednesday, September 19, 1984
8:30 a. m. -4:00 p.m,
at
MSNJ HEADQUARTERS, Lawrenceville
Those CME managers and planners in attendance will: Gaini ^
exposure to a broad range of needs assessment procedures-
from faculty and fellow participants; Choose those needs
assessment concepts and techniques which will best apply tc
their particular environment; Observe one or more accredita-
tion site survey scenarios and determine the collegial and
consultative nature of the site survey process and define whatj
is expected in the accreditation and site survey process.
PROGRAM CO-CHAIRMAN:
Alfred A. Alessi, M.D.
Director of Medical Education
Academy of Medicine of New Jersey
Brewster Miller, M.D.
Director of Medical Education r
Somerset Medical Center
of New Jersey
for further information contact:
EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
Two Princess Road, Lawrenceville, NJ 08648
(609) 896-1717
LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
OCTOBER 3, 1984
ACUTE MYOCARDIAL INFARCTION
MODERATOR: WILLIAM FRANKL, M.D.
3:00 CASE PRESENTATION Edward Catherwood, M.D.
3:30 RELATIVE VALUE OF TREADMILL EXERCISE TESTING Stuart Snyder, M.D.
4:00 THALLIUM IMAGING AND RADIONUCLIDE ANGIOGRAPHY
EARLY AFTER MYOCARDIAL INFARCTION Abdulmassih S. Iskandrian, M.D.
4:30 CORONARY ARTERIOGRAPHY FOR PATIENTS WITH ACUTE MYOCARDIAL
INFARCTION: SHOULD IT BE DONE IN ALL PATIENTS? Charles E. Bemis, M.D.
5:00 THROMBOLYSIS IN ACUTE MYOCARDIAL INFARCTION:
INDICATIONS, NEW AGENTS, AND RESULTS Demetrios Kimbiris, M.D.
LECTURE HALL “A”— 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
**WINE & CHEESE SERVED FOLLOWING CONFERENCE**
812
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
2 ND-YAC Laser in G.I.
16 The Physician as a Patient
30 Sanity in Today’s Beta-Blocker
Market
9 AM.— Crean Hall, St. Francis
Medical Center, Trenton
(St. Francis Medical Center)
6 Antibiotic Update
9- 1 0 A.M.— Freehold Area Hospital
(AMNJ)
7 AIDS
1 -2:30 P.M.— Christ Hospital, Jersey
City
(AMNJ)
7 Medical Grand Rounds
14 12 noon-1 P.M.— Rutgers Medical
21 School, Medical Education Bldg.,
)28 New Brunswick
(UMDNJ and AMNJ)
7 Medicine Morbidity and Mortality
Conference
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jersey. This special issue
illuminates the beginnings of our health care system and the growth of medical
care: essays highlight those talented individuals who devoted themselves to this
system, and commentaries present the development of specialized care in as-
sociated fields of medicine. Plus a special photography section highlighting three
statewide exhibits.
Copies of this issue are available by sending $5.00 (check or money order)
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648. All MSNJ members will
receive one copy of this issue.
Name —
Address
■
Enclose a $5.00 check or money order for each copy.
8-9 A M.— Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
7 Common Dermatoses
1:30-2:30 P.M. — Essex County
Hospital Center, Cedar Grove
(AMNJ)
7 Endocrine Conferences
14 3:30-5 P M. — Rotates between
21 Newark Beth Israel Medical Center,
28 University Hospital, United
Hospitals Medical Center, Newark,
and VA Medical Center, East
Orange
(Endocrinology Section. AMNJ)
13 Topic To Be Announced
8- 1 0 P.M.— Schering Corp.,
Kenilworth
(NJ Dermatological Society and
AMNJ)
1 4 Early Diagnosis an d Treatment of
Commonly Seen Office Problems
8:30 A.M. -5 P.M. — Medical Society of
NJ, Lawrenceville
(NJ Academy of Family
Physicians and AMNJ)
14 Dermatologic Manifestations of
Life-Threatening Illness
1-2:30 P.M.— Bldg. 93, VA Medical
Center, Lyons
(VA Medical Center and AMNJ)
15 Diagnosis and Management of
Anaerobic Infection
5-7:30 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
15 Case Presentations
8-10 P.M. — The Mountainside
Hospital, Montclair
43 L. 81— NUMBER 9— SEPTEMBER 1984
813
ARE YOU A SAINT MICHAEL’S ALUMNUS?
Saint Michael’s Medical Center, Newark, NJ, a 117 year old
teaching hospital, is forming a medical alumni association. We
are seeking some 5,000 physicians who served as residents
and interns. Over the years many of our former house staff
members have relocated making consistant communication
difficult.
Our alumni association will be oriented towards four goals:
professional, medical, social and educational. Plans are
already being made for a medical reunion dinner and sym-
posium in the fall.
If you are a former member of Saint Michael’s house staff or
know another staffer's whereabouts,
877-5494 or write to:
SAINT MICHAEL’S MEDICAL CENTER
268 Dr. Martin Luther King, Jr. Blvd.
Newark, NJ 07102
attn: Office of Public Affairs
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
For the Investigation of
Problems of Human Infertility
i
The Foundation provides a complete
diagnostic and consultation service for in- j
fertile couples. Investigations are con-
ducted by well-known specialists in con- j
junction with consultants in the various
fields of medicine related to infertility.
The Foundation is supported by an in- !
house modern laboratory equipped to do
most tests required for diagnosis and
treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual and electro-acupuncture, applicable toward the 200-
hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
Sept. 9-11, 1984 and again the weekend of Oct. 26-28, 1984 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
office journal, Acupuncture & Electro-Therap. Res., Int.J (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Research
Foundation and the Neuroscience Dept, of Long Island College
Hospital, Pharmacology Dept, of The Chicago Medical School.
Also eligible for AMA/CME credit. For information, contact Y.
Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC 10032. Tel:
(212) 781-6262 or (212) WA8-0658, or Saul Heller, M.D., Tel:
(212) 838-7514.
please call (201)
814
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY:
(NJ Gastroenterological Society
and AMNJ)
20 New Treatment Modes and
Implications for the Future in
Diabetes
12 noon— St. Mary’s Hospital,
Orange
(St. Mary's Hospital and AMNJ)
21 Dermatological Conferences
6-9 P.M.— Rutgers Community
Health Plan, U.S. Hwy. 1 & Rt. 18,
New Brunswick
(UMDNJ and AMNJ)
28 Dermatologic Manifestations of
Life-Threatening Illness
1-2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
28 Controversies in Geriatrics
I -5 P.M. —Medical Society of NJ,
Lawreneeville
(AMNJ)
29 Laser Treatment of Massive GI
Hemorrhage
I I AM.- 12 noon — St. Joseph's
Hospital and Medical Center,
Paterson
(AMNJ)
fEUROLOGY/ PSYCHIATRY
)ct.
1 Cocaine Addiction in a Hysterical
Woman
8:15-10:30 P.M. —Marquette Road,
Upper Montclair
(Essex Psychiatric Seminar and
AMNJ)
3 Use of Botulin Toxin To Treat
Essential Blepharospasm
6-9 P.M. — The Manor, West Orange
(AMNJ)
4 Research Update: Aging, The
Elderly, and E.C.T.
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
5 Lecture Series
12 1:30-5:30 P.M. —Trenton
19 Psychiatric Hospital
|26 (NJ Division of Mental Health and
Hospitals and AMNJ)
L 1 Gender, Identity, Cognitive
Development, and Emotional
Conflict
8 P.M. — Saint Barnabas Medical
Center, Livingston
(NJ Psychoanalytic Society and
AMNJ)
15 Lecture Series
8:30- 1 0:30 P.M. — 30 1 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
16 Current Management of
Intracerebral Hemorrhage
12 noon— St. Mary’s Hospital,
Orange
(AMNJ)
17 Personality Variables in
Substance Abuse
1-3 P.M.— Fair Oaks Hospital,
Summit
(Fair Oaks Hospital and AMNJ)
1 8 Coordination of Psychiatric
Treatment in the Hospital and
Community
3-4 P.M.— Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital and
AMNJ)
19 The State of Psychiatry for 1984
8:30-10:30 P.M.— Coachman Inn,
Cranford
(NJ Psychiatric Association and
AMNJ)
23 Alzheimer’s Disease
24 9:15 AM. -4:45 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
24 Affective Disorders: New
Advances in Diagnosis and
Treatment
1 -3 P.M. — Fair Oaks Hospital,
Summit
(Fair Oaks Hospital and AMNJ)
Nov.
1 Psychotherapy Outcome Research
8 The Wish To Be Held
15 Smoking, Personality, and Health
29 Humor In Psychotherapy
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
2 Lecture Series
9 1:30-5:30 P.M. —Trenton
16 Psychiatric Hospital
23 (NJ Division of Mental Health and
30 Hospitals and AMNJ)
3 Clinical Issues in Adoption
8:30 AM. -5 P.M. —Fair Oaks
Hospital, Summit
(Fair Oaks Hospital and AMNJ)
5 Psychosomatic Disorder Followed
by a Tic
8:15-10:30 P.M.— 192 Chittenden
Road, Clifton
(Essex Psychiatric Seminar and
AMNJ)
7 Therapeutic Touch — Research
and Clinical Findings
1-2:30 P.M.— VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
7 Louis Loeser Memorial Lecture
8- 1 0 P.M.— South Mountain School,
South Orange
(NJ Psychiatric Association. NJ
Medical School and AMNJ)
8 Certain Aspects of Forensic
Psychiatry Applicable to the
Chronic Care Psychiatric Hospital
1 -3 P.M.— Essex County Hospital
Center, Cedar Grove
(Essex County Hospital and
AMNJ)
14 Industrial /Occupational Medicine
and Psychiatry
9: 1 5 AM. -4:30 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
1 5 Topic To Be Announced
8:30 P.M. —Hackensack Medical
Center
(NJ Psychoanalytic Society and
AMNJ)
15 Psychopharmacology I
29 Psychopharmacology II
3-4 P.M. —Ancora Psychiatric
Hospital, Hammonton
(AMNJ)
19 Lecture Series
8:30- 1 0:30 P.M. — 30 1 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
OBSTETRICS/GYNECOLOGY
Oct.
25 Semi-Annual Meeting
9 AM. -5 P.M. — Rutgers Medical
School, Piscataway
(NJ Obstetrical and Gynecological
Society and AMNJ)
PATHOLOGY
Oct.
25 DEIS — An Update
1 1 AM.- 12 noon— St. Joseph’s
Hospital and Medical Center,
Paterson
(St Joseph's Hospital and AMNJ)
Nov.
1 7 Surgical Pathology of the Breast:
Diagnosis and Therapeutic
Implications
9 AM.- 1 P.M.— Rutgers Medical
School, Piscataway
(NJ Society of Pathologists and
AMNJ)
PEDIATRICS
Oct.
10 Pediatric Gastroenterology
Update for the Practitioner
9 AM. -3 P.M. — Newark Beth Israel
Medical Center
(Newark Beth Israel Medical
Center and AMNJ)
1 7 Childhood Oncology of the Bone,
Blood, and Brain
1 -4 P.M.— Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
20 First Annual Tri-State Gifted
Conference
9 AM.-3 P.M.— Camden County
College, Blackwood
(Educational Information and
Resource Center)
30 AIDS in Children
7-9 P.M. —Englewood Hospital
Learning Center, Englewood
(Englewood Hospital and AMNJ)
Nov.
6 Newer Aspects of Pneumonia in
Infants and Children
8:30-9:30 AM.— Newark Beth Israel
Medical Center
(Newark Beth Israel Medical
Center and AMNJ)
7 Current Diagnosis and
Management of Pediatric
Rheumatologic Diseases
8:30 A.M. -2 P.M.— Rutgers Medical
School, Piscataway
(Arthritis Foundation. NJ Chapter.
NJ Rheumatism Association, and
AMNJ)
RADIOLOGY
Oct.
1 1 New Aspects of Ultrasonography
18 Saint Barnabas Medical Center,
Livingston
(NJ Institute of Ultrasound in
/OL. 81— NUMBER 9— SEPTEMBER 1984
815
it rs Not What You Know,
It’s How You Record It.
Most busy
physicians
find continuing
medical education,
credits easier to
collect than
to remember.
So the Academy
of Medicine of
New Jersey is offer-
ing an easy system
for recording and reporting
CME credits for AMA recognition
as well as Medical Society and
professional organization membership.
A computerized CME recordkeeping
system is available to every New Jersey
physician. All you do is send us a
reporting card (which your office staff can
complete).
We'll keep
your
records
and keep
you
informed
semi-
annually
of your
accumulation.
This service is free to Academy
members. Non-members (whom
we encourage to join) pay $30 per year.
If you're interested, complete and mail this
coupon.
Note: The Medical Society of New
Jersey accepts these CME Reports as
documentation to meet CME
membership requirements.
Please register me for AMNJ's computerized CME record-keeping service.
Name
Address
City
State
Zip
Telephone Number
Your New Jersey Medical License No. (five numerical digits only).
Academy member: Yes □
No □ Please enclose check
Interested in Academy membership: Yes □ No □
Mail to: Academy of Medicine of New Jersey, 2 Princess Road, Lawrenceville, NJ 08648
816
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Medicine. Radiological Society of
NJ. and AMNJ)
25 Visiting Professorship Program
1:30-5 P.M. — Saint Barnabas
Medical Center, Livingston
(Dept, of Radiology. Saint
Barnabas Medical Center, and
AMNJ)
Nov.
8 Current Status of Carotid Imaging
7:30 P.M. — Saint Barnabas Medical
Center, Livingston
(NJ Institute of Ultrasound in
Medicine. Radiological Society of
NJ. and AMNJ)
2 1 Radiation Therapy Oncology
Group
6:30-9:30 P.M —The Manor, West
Orange
(Radiotherapy Section AMNJ)
SURGICAL SPECIALTIES
Oct.
23 Ophthalmology Update
1984-1985
8-10 P.M. —Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
Nov.
27 Breast Reconstruction After
Mastectomy
8-10 P.M. —Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
MISCELLANEOUS
Oct.
4 Medical Hypnosis Course
11 4-8 P.M.— Carrier Foundation, Belle
18 Meade
(Carrier Foundation and AMNJ)
17 Most Useful Visual Aids for
Geriatric Patients
7:30 P.M. — Saint Barnabas Medical
Center, Livingston
(Ophthalmology Section, AMNJ)
18 Computers in Medicine
1 1 A.M.-12 noon— St. Joseph’s
Hospital and Medical Center,
Paterson
(AMNJ)
18 Nurse as Expert Witness in Court
12 noon-1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
20 Potential Ecological and Medical
Disasters
8:30 A.M.-3:30 P.M. — Location to be
announced
(NJ Chapter of Physicians for
Social Responsibility and AMNJ)
Nov.
1 Medical Hypnosis Course
8 4-8 P.M. —Carrier Foundation, Belle
15 Meade
29 (Carrier Foundation and AMNJ)
1 4 Withholding or Withdrawal of Life
Support — Legal and
Ethical /Moral Aspects
8:30 A.M.-3:30 P.M. —Hilton Inn,
Tinton Falls
(NJ Society oj Critical Care
Medicine and AMNJ)
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN°/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily
AVAILABLE: Bottles of 100, 500
LIPO-NICIN*7100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg
Niacinamide 75 mg.
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) . 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500
Indications: For use as a vasodi
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg or 250 mg is one of the
therapeutic effects that often
produce psychological benefits
to the patient
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur
Contraindications: Patients with
known Idiosyncrasy to nicotinic
acid or other components of the
drug Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding
Write for literature and samples
(BRcWWJfc THE BROWN PHARMACEUTICAL CO.. INC. pf
2500 West Sixth Street, Los Angeles, California 90057
MEDICAL PRACTICE
SALES AND APPRAISALS
We specialize in the valuation and selling of
medical practices. If interested in buying or selling
a medical practice, contact our Brokerage
Division at:
Health Care Personnel Consulting, Inc.
403 GSB Building
1 Belmont Avenue
Bala Cynwyd, PA 19004
215-667-8630
The Journal of the Medical Society of New Jersey
announces the reprinting of the
\
WILLIAM CARLOS WILLIAMS
COMMEMORATIVE ISSUE
September, 1983
Honoring the 100th anniversary of the birth of New Jersey’s prize-winning poet and physician.
Included in this handsomely illustrated, full-color issue will be original articles by persons
close to William Carlos Williams, artwork from his social and intellectual circle, and samples
of his finest writings.
Copies of this special issue are available by sending $5.00 for each (check or money order)
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648.
Please send a copy of the WilSiam Carlos Williams Commemorative Issue to:
Enclose a $5.00 check or money order for each copy.
Financial Planners
for the
Medical Profession
Investments, Pensions, Insurance, Etc.
• Honest
• Sophisticated
• Profusely Referenced
609-778-4388
818
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
•» V.IJ'
To Career Oriented £mo
® Comp..«vel„come
a nM"r'"te"r““
™ F,exib,e schedule
^ CME credits
g “*»»"<irural,e,1,ns!
j E v°* p«.*,PWa ,„d llw
Frrrn.
certification
«ted J5S^Jw*c'«n Associates p .
family practjce i f °^rd e'igibi/ity in ern 'A-' P^fers dedi-
emergency deparfm ,na med'cine or ™ 9encV medicine
Ca» or write to us foXPeri|nCe ^ With Prior
"-'■-Kss;::
DOC
>ik;
xk:
3MC
DOCTORS:
Are your billing, filing and business sys-
tems in your office running as smoothly and
efficiently as your medical practice?
If not, Mary Ann Hamburger, Associates
is your answer. Sixteen years ago Mary Ann
Hamburger of Maplewood, New Jersey took
a job for a doctor managing this office.
Today, as a medical management consult-
ant, Mary Ann knows where the problem
areas are and she can make sure that
everything runs smoothly for the physician
and his or her staff. Part of her job is to
make certain that the current billing system
is running efficiently, to update the filing
system, work with third party billing, help
clear up any booking problems as far as
appointments are concerned and work with
any other problems relating to the business
side of the medical practice.
Mary Ann’s skills will benefit any doctor
in an existing practice and all new doctors
who are setting up their practices in the
near future. Her services can also include
the hiring aspect of the doctor’s offices if
desired.
FOR FURTHER INFORMATION ON
MEDICAL MANAGEMENT, CONTACT
MARY ANN HAMBURGER, ASSOCIATES
AT 201-763-7394.
It’s Your Affair,
So Don’t Lift A Finger
Since we want your
special day to be carefree
just lift the phone and call
Perfect Catering For A Perfect Affair
Trenton, New Jersey
609-890-0778
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/OL. 81— NUMBER 9 — SEPTEMBER 1984
819
NEUROLOGIST wanted for diagnosis, treatment
and patient care in all areas of neurology; Re-
quires M.D. degree and three years training as a
resident in neurology; 40 hours per week;
$66,500.00 per year. Position located in Southern
New Jersey. Mail resume to CN053, A.E.C. #74,
Trenton, N.J. 08625. Resumes must be received
within two weeks of publication date of this
advertisement.
PRIMARY CARE PHYSICIAN— Family Practice or
Internal Medicine BE/BC— Solo and partnership
opportunities, immediate and July 1985, in central
New Jersey; convenient to Philadelphia and New
York; excellent local housing, schools, univer-
sities, cultural activities: hospital affiliation in 350
bed full service facility; financial assistance avail-
able; preference given to graduates of major
medical schools and programs; reply box
NJ Physician Recruitment Association
P.O. Box 35
Pennington, NJ 08534
Need A Temporary Physician?
CompHealth treats your practice as if it were our
own during: vacations, CMEs, recruiting, clinic
start-up or other absences.
Want Free Time While You
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Join CompHealth’s Locum Tenens Physician Group.
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For further information about temporary coverage
or locum tenens practice opportunities, call:
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A Physician Group
WILSON ROSS, Regional Administrator
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Trenton, NJ 08608
Telephone: 609-392-1111
IfiMUgL
A great way of life
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A SPECIAL PRACTICE FOR SPECIALISTS
If you’re a surgeon or OB/GYN or other medi-
cal specialist, the Air Force may have a special
practice for you.
What makes it special? You’ll enjoy an excel-
lent pay and benefits package. Your regular work-
ing hours will allow you to spend more time with
your family. You’ll receive 30 days of vacation with
pay each year. And you will work with modern
equipment and some of the most highly trained
professionals in the world, serving your country
and your patients. Now that’s special! Find out just
how special your practice can be.
Contact:
Maj. Sandra Klassy
609-723-0455
*
820
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
CLASSIFIED ADVERTISEMENTS
OBSTETRICS-GYNECOLOGY— Board
eligible, NJ licensed, subspecialty fellow-
ship experience in Micro-surgery, Hys-
teroscopy, Infertility, Artificial insemina-
tion, Gyn-endocrinology. Seeks practice
opportunity. Available now. Write Box No.
96, JMSNJ.
ORTHOPAEDIC SURGEON— American
graduate, trained at Downstate Medical
Center, NY. Seeks position, solo, group or
hospital based. Call 212-819-8706 (busi-
ness hours).
PHYSICIAN— Lifetime NJ resident seeks
position in a pediatric group after com-
pletion of postgraduate training. Avail-
able July 1985. Please contact Charles
Geneslaw, 8372 Loveridge Court. Rich-
mond, VA 23229.
PHYSICIAN— MD for industrial and oc-
cupational health care facility in the
South Jersey resort area Opening No-
vember or December. Duties to include
emergency, follow-up/and return to work
treatment, as well as pre-placement and
annual physical exams. Send CV to Box
INo. 95, JMSNJ.
■
EQUIPMENT FOR SALE— Various office
items including physical therapy equip-
ment. Please phone for full listing or in-
formation. Livingston. 201-994-3200.
FOR SALE — 45-year old Family Practice
in East Orange, NJ. Must sell due to
death of physician. Contact: A. D. Rosen,
14333 Addison Street, **115, Sherman
Oaks, CA 91423. 818-789-2715.
FOR SALE — South Orange, 3 story
home, professional zone near all trans-
portation within 10 minutes of St.
Barnabas, St. Marys Hospital and Hospi-
tal Center at Orange. Please address in-
quires to Box No. 92, JMSNJ.
OFFICE SPACE TO SUBLET— Beauti-
fully furnished office in professional
building in prestigious Haddonfield,
South Jersey. Ideal for surgeon or sub-
specialist. 609-354-1511.
OFFICE SPACE TO SUBLET— Liv-
ingston. 349 E. Northfield Road, near St.
Barnabas. Fully furnished, all utilities in-
cluded. Close to public transportation.
Available immediately. 201-992-4442.
NEEDED PHYSICIANS— For successful
well known walk-in medical office center.
Central NJ. Full and part time, skilled
(personable American-trained MDs. Send
CV to E.V. McGinley, MD, 1005 N. Wash-
ington Avenue, Green Brook, NJ 08812.
201-968-8900.
OFFICE SPACE TO SHARE— Mor-
ristown, central location. Near hospital,
fully equipped, newly decorated. All util-
ities included. Ample parking available.
Near public transportation. Available im-
mediately. (201) 267-2555.
OFFICE SPACE TO SHARE— North
Brunswick/Somerset. Fully equipped
pediatricians’ office located on Highway
27 in North Brunswick/Somerset area,
in new professional building. Call
201-828-4850 for information.
OFFICE SPACE TO SHARE— Westfield,
central location. Near hospital, fully
equipped, attractively decorated. All util-
ities included. Ample parking available.
Near public transportation. Available im-
mediately. (201) 267-2555.
OFFICE SPACE — Atlantic City. For rent,
medical office fully equipped and
furnished. 1,300 square feet. Call
609-822-0270.
OFFICE FOR SHARE or RENT— New
Brunswick, Highland Park area.
Furnished, 700 square feet. Ample park-
ing. Close to the hospital. 8500/month
plus utilities, for rent. For share,
$300/month including utilities. Call
201-572-5050 or 572-7553.
OFFICE SPACE — South Orange. Com-
plete professional office for rent. 1,500
square feet, parking. Telephone
201-751-3300.
OFFICE SPACE — For Rent. Professional
office for rent in West New York. Comer
location with parking space on Doctor’s
row. Close to hospital and public trans-
portation. Call 201-278-1000 or
201-947-4333.
FOR RENT— Professional office space for
rent Millbum prestigious building, 775
square feet. On-site parking, on bus
route. Call 201-731-1900.
RATE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
WORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
numbers, hyphenated words. Count name and address as five words, telephone number as one word, and “Write Box No. 000,
c/o JMSNJ” as six words. COPY DEADLINE: Fifth of preceding month.
PRACTICE FOR SALE
Pediatric Practice— Northeast New Jersey.
Established, growing practice. Attractive lease,
good staff, fully equipped, pleasant community.
Address inquiries to:
The Health Care Group
400 GSB Building
Bala Cynwyd, PA 19004
215-667-8630
It’s A Major Medical Explosion
The Lakewood, Toms River and Point Pleasant hospitals
are all going ahead with major expansion programs . . .
Bricktown opens new facility.
Cross River Professional Center
400 to 2,300 Square Feet
'A Mile South of Kimball Medical Center
• $12 per square foot minutes to all four major
• Graduated rent schedules hospitals
® Ownership options available • Private entrances and all
• Fully landscaped services available
• Centrally located and 10 • Equipment leases available
6KRRYMOR ENTERPRISES Protected
1200 River Avenue (Route 9), Lakewood, NJ 08701 • (201) 367-2226
VOL. 81— NUMBER 9— SEPTEMBER 1984
821
HELPER BROUGHTON I X .
4 World Trade Center
New York, N.Y. 10048
INVESTMENT BANKERS AND SPECIALISTS
IN MEDICALLY RELATED NEW ISSUES AND
TRADING SECURITIES
STEVEN HIRSCH
Director of Professional Corporations and Fund Management
In New York: (212) 938-1210
Out of State: (800) 221-4188
NOW LEASING . . .
_ ii + \A/ith c;iini
Preconstruction rates. Excellent location with superb facilities.
Adjacent to commercial and residential centers.
interiors to your specifications with support services Reared
Ownership possibilities. Call Michael Lewis at (609) 235-16M.
A— Existing;
B, C, D: Completion 1/30/85
east gate
MEDICAL
CENTER
Church Street & Gaither Drive
Mount Laurel, New Jersey 08054
822
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Journal « y "w
’'S New Jersey
OCTOBER 1984
n rr
h- tr*
S3*
P
IN VITRO FERTILIZATION:
THE HUMAN OVUM AT VARIOUS STAGES
E. & W. BLANKSTEEN
E. & W. BLANKSTEEN AGENCY, INC.
ADMINISTRATORS
THE MEDICAL SOCIETY OF NEW JERSEV
ENDORSED PLANS OF:
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MAJOR MEDICAL
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6-POINT HIGH LIMIT ACCIDENT
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NON-GMGOP PROGRAMS OF:
HOMEOWNER’S
OFFICE PACKAGE
LIFE
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Jersey City, WJl 07201 -
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he IBM Personal Computer
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idred physicians are using the MEDI-SCAN System — join them in making the IBM PC-XT “A tool for modem
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OL. 81 -NUMBER 10— OCTOBER 1984
823
October 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 766
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirseh, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica, M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Publication Committee
Paul J. Hirseh, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
La Verne Fioretti
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
Editor
Arthur Krosniek, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Graphic Artist
Frank Cecala
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. DElia, M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
Henry J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood)
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaiyngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Alan J. Lippman, M.D. (Oncol)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Edwin L. Rothfeld, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) exo
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of N
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Print;
Co. Whole number of issues 967. Member’s subscription ($10) is included in Society dues. Rates for nonmembf
S20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, T
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and additioi
entry office. Copyright 1984 by the Medical Society of New Jersey.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
824
ist, Cranford
ity of Ne||j$i
Henry Miiteur, M.D., Cara
Speaker ofine House of Delegates of the Medical
"Sadly, as the cost of medical
care increases and the scope of
many health insurance pro-
grams decreases, my patients
wind up in a terrible squeeze.
|I found a very satisfactory solu-
tion. I became a participating
physician in Health Ways.
With Health Ways, I can prac-
tice the kind of medicine that
will truly benefit my patients
I without worrying about their
financial positions because of
the Health Ways unique physi-
cian reimbursement policy.
That's a significant plus.
In addition, the administra-
tive and financial structure of
Health Ways is fighting the as-
tonishing escalation of costs by
covering procedures easily done
on an out-patient basis rather
than in the hospital. That makes
a lot of sense. So does their pol-
icy of covering routine check-ups.
And since the bills go directly
to Health Ways, the specter of
unpaid bills is eliminated."
Health Ways can be most
valuable to your practice too.
For more information, call Jon
Marsicano, M.D., Vice Presi-
dent, Medical Affairs, at 1-800-
624-0720.
HealthWays
YOUR WAY TO BETTErVmEALTI I CARE
)L. 81— NUMBER 10— OCTOBER 1984
825
The Journal
of the Medical
Society of
New Jersey
OCTOBER 1!
Membership Newsletter
Professional Liability Commentary
Editorials
Hospital Governing Boards
hbh Contributions
849 Initial Experience with In Vitro Fertilization in New Jersey
E. Kemmann, M.D., D. Colburn, M.D., S. Pasquale, M.D., J. Nosher, M.D.,
V. T. Brandeis, M.D., A.M. Delist M.D., R.M. Shelden, M.D.,
New Brunswick
857 Myth or Fact: Can Women Self-Diagnose Pregnancy?
GA. Bachmann, M.D., New Brunswick
863 Risks Associated with Post-Traumatic Flashbacks
A. Burstein, M.D., Freehold
867 Midtrimester Amniocentesis for Prenatal Diagnosis
A Ghiatas, M.D., Long Branch
870 Microsurgical Resection of AV Malformations from Vital Areas
of the Brain
O.R. Hubschmann, M.D., andA.J. Krieger, M.D., Newark
875 Effects of AIDS on Various Aspects of Blood Banking
M. Kuriyan, M.D., F. Muschenheim, M.D., C. Bianco, M.D.,
New Brunswick
878 Androgen-Secreting Ovarian Tumors in Postmenopausal Women
W. B. Ober, M.D., Hackensack
884 Imaging: Magnetic Resonance Imaging (MRI)
K.L. Jewel, M.D., B.I. Loigman, M.D.. R.F. Mattem, M.D.,
S.D. Richman, M.D., C.C. Royer, M.D., CA. Whelan, M.D., Caldwell
889 Update: Immunizations During Pregnancy
S.R. Preblud, M.D., KJ. Bart M.D., A.R. Hinman, M.D., Atlanta, GA
89 1 Commentary: Update of Diagnostic Related Groups
M.E. Johnson, Lawrenceville
829
837
841
847
i Doctors’ Notebook i . ~
893 Trustees’ Minutes: July 15, 1984
894 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
895 MSNJ Auxiliary, Grace Gellman
895 New Members
896 Tamisiea Award
896 Physicians Seeking Location in New Jersey
MSNJ Departments
899 CME Calendar
903 Letters to the Editor
904 Book Reviews
906 Obituaries
908 Information for Authors
On The Cover: The first in vitro
fertilization program in New Jer-
sey is underway and the results
are in. The complete story on this
new method of treating infertility
begins on page 849.
IN VJTBO FERTILIZATION
THE HUMAN OVUM AT VARIOUS STAGES
826
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program, -J
for more information please call A ®
(201) 456-3200. Ik,
THE NEW JERSEY ACADEMY OF FAMILY PHYSICIANS
presents its
33rd ANNUAL CONVENTION
AND SCIENTIFIC MEETING
March 13-16, 1985
at
HARRAH’S TRUMP PLAZA HOTEL & CASINO
ATLANTIC CITY, NEW JERSEY
The Scientific Meeting will include speakers on:
“Cardiology, Infectious Diseases, Dermatology and Sports
Medicine” in the Plenary Sessions
and
the Workshops will include sessions on:
“Flexible Sigmoidoscopy, Minor Office Surgery, Basic Casting
Techniques and Cardiac Rehabilitation as well as additional
subjects of Clinical Importance”
CREDIT HOURS
14 Hours AAFP Prescribed Credit
14 Category I Credits
For Further information Contact:
Jean M. Winkler
Executive Secretary
New Jersey Academy of Family Physicians
Two Princess Road
Lawrenceville, New Jersey 08648
(609) 896-9130
828
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS:
Membership
Newsletter
fHE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 15
O-DAY LIMITATION ON ALL PRESCRIPTIONS
The Board of Trustees, on Januaiy 15 1984, ap-
roved a recommendation from the Council on Mental
[ealth, calling for an extension of the 30-day limitation
n the filling of prescriptions for controlled substances
fter the date issued (as proposed in an amendment
) N.JAC. 8:65-7.5) to include all drugs. This should
ot affect medications that are taken continuously,
uch as antibiotics, birth control pills, and diabetic
nd thyroid drugs, as these prescriptions can be made
ut to allow a certain number of refills.
To support the forwarding of this recommendation
) the New Jersey State Department of Health, the
ouncil on Mental Health is requesting members to
Libmit instances in which they feel prescriptions have
een filled after 30 days of issuance which have caused
roblems in patients, i.e. medications used for con-
itions other than those for which the prescriptions
rere written, lack of control of use of medications.
Please forward comments to George L. Trieben-
acher, M.D., Chairman, Council on Mental Health, at
pe Medical Society of New Jersey headquarters.
SYCHOTHERAFY PROGRESS NOTES
The Division of Medical Assistance and Health Ser-
ices has submitted a proposed rule concerning the
equirements for Psychotherapy Progress Notes to the
lew Jersey Register. The rule describes the essential
omponents of a psychotherapy progress note, includ-
ig, but not limited to, date and duration of service,
iame of modality used, notations of treatment results,
tc. The full text of the proposal will appear in the
legister. If there are any problems or questions, con-
act Henry W. Hardy, Esq., Administrative Practice Of-
ficer, (1-609) 292-7079.
GERIATRIC CARE
Every physician has geriatric patients. While many
ieople over the age of 65 remain healthy and active,
ome have medical problems which require assistance
torn others. Some of the common problems include:
ack of knowledge regarding benefits, entitlements,
nd the aging process; management of chronic pain;
motional and financial strain; anxiety; depression;
Juilt; and time management. There are support groups
available to help these patients, such as the New Jersey
Senior Citizens Hotline, (1-800) 792-8820, and county
offices on aging.
FOREIGN MEDICAL GRADUATES
Foreign medical graduates’ (FMGs) role in organized
medicine was explored at the AMA Ad Hoc Committee
Meeting on FMGs, held on September 5, 1984. The
purpose of the Committee is to study the problems and
special concerns of FMGs, including U.S. citizens who
studied in foreign medical schools. One of the expected
results is increased involvement of FMGs in organized
medicine.
PRESCRIPTION ABUSE
Prescription Abuse Data Synthesis (PADS) project of
the AMA has resulted in 1 1 arrests and 8 convictions
in Michigan. Some 41 cases still are under investiga-
tion by enforcement agencies participating in a task
force for identifying practitioners who prescribe excep-
tionally high volumes of controlled drugs. The law en-
forcement agencies, in consultation with the Michigan
Medical Society and the Department of Licensing and
Regulation, identified the practitioners by coordi-
nating state efforts with computerized federal tracking
systems. Michigan authorities said that prescription
drugs had been abused or misused by more Americans
than cocaine, hallucinogens, or heroin. Most are
diverted at the retail level, including physicians' offices,
pharmacies, and clinics.
ALTERNATIVE MEDICAL LIABILITY ACT
AMA testified in opposition to H.R 5400 which es-
tablishes an alternative system for settlement of pro-
fessional liability claims arising from the provision of
health care services paid for or provided by federal
programs. H.R 5400 permits a physician or hospital
to offer compensation to an injured patient for that
patient’s “net economic loss" and by so doing foreclose
the patient from suits for compensation in the court
system. The AMA stated that it is not clear that the
bill will reduce any incidences of the practice of "de-
fensive medicine." Rather than reduce aggregate
health care costs, the bill is likely to increase them and
lead to higher liability premiums. (Subcommittee on
Health, House Ways and Means Committee.)
: A)L. 81— NUMBER 10— OCTOBER 1984
829
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject
MSNJ
Position
Committee
Present Status
S-70
Codey
To change requirements for
eligibility to be Commissioner of
Health
Active Opposition
Senate: IHW
In committee
S-lll
Bubba
To require a physician to present
surgical consent forms at the time
surgery is agreed upon
Active Opposition
Senate: LIP
In committee
S-243
Hagedom
To provide procedures for
involuntary civil commitment of
the mentally ill
Active Opposition
Senate: IHW
In committee
S-317
Lynch
To provide for regulation of the
practice of contact lens dispensing
Active Opposition
Senate: LIP
Withdrawn
by sponsor
S-424
Dorsey
To provide for the abolishment of
certain state agencies for specific
periods of time and to create a
Joint Legislative Committee on
Regulatory Agencies
Active Support
Senate: SGF&IR&VA
In committee
S-607
Bassano
To require the padding of all metal
bars in school buses with energy-
absorbing materials to be included
in the State Board of Education's
rules and regulations
Active Support
Senate: LPS&D
In committee
S-723
Brown
To require the State Department
of Health to prepare a booklet on
breast cancer and require
physicians to give a copy of the
booklet to breast cancer patients
Active Opposition
Senate: IHW
In committee
S-752
Hirkala
To provide that certain
information of hospitals and long-
term health care facility review
committees be considered
confidential
Active Support
Senate: IHW
In committee
S-754
Hirkala
To provide immunity from civil
liability to members of hospital
governing bodies in connection
with certain review actions taken
by them
Active Support
Senate: J
In committee
S-1067
Feldman
To establish and license two
categories of social workers
Active Opposition
Senate: IHW
In committee
S-1079
Dumont
Provides for a three-year statute of
limitations, except for fraud,
intentional concealment, or
nontherapeutic or diagnostic
purpose. Minors have until
age 1 1 on any injuiy prior to age 8
Active Support
Senate: J
In committee
S-ll 12
To establish a cap on the amount
of damages which may be awarded
for pain and suffering in certain
civil actions
Active Support
Senate: J
In committee
S-1135
Dalton
To eliminate certain sources of
windfall benefits in personal
injury and wrongful death actions
Active Support
Senate: J
In committee
S-1140
Feldman
To impose certain requirements
on the plaintiff in a medical
malpractice proceeding
Active Support
Senate: J
In committee
S-1182
Saxton
To establish the Automobile
Insurance Medical Fee Schedule
Board
Active Opposition
Senate: LIP
In committee
S-1190
Feldman
To authorize a court to award
reasonable attorney’s fees to a
party who prevails against a
frivolous claim for relief in a civil
action
Active Support
Senate: J
In committee
:
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
830
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject
MSNJ
Position
Committee
Present Status
S-1349
Lipman
To require prior patient written
authorization before a doctor can
perform either a biopsy or
mastectomy, or both, in cases of
surgery for a breast tumor
Active Opposition
Senate: IHW
Out of
committee,
amended;
2nd reading
A-115
Otlowski
To authorize optometrists to
prescribe a limited number of eye
medications
Active Opposition
Assembly: HERP
In committee
A-708
To create a temporary committee
to study Diagnosis Related Group
System used for setting hospital
rates and appropriate $45,000
Active Support
Assembly: CHHS
In committee
A-926
Weidel
To create an Automobile
Insurance Fee Schedule Board in
the Department of Insurance to
adopt a reasonable fee schedule for
medical services arising from
passenger automobile accidents
Active Opposition
Assembly: BI
In committee
A-960
Miller
To permit individual patients or
insurers to appeal hospital bills in
cases of assignments under the
Diagnosis Related Groups
Active Support
Assembly: CHHS
In committee
A-963
Miller
To eliminate the Diagnosis Related
Groups methodology and replace it
with one to be devised by the
Department of Health in one year
Active Support
Assembly: CHHS
In committee
A- 1056
Muziani
To require attending physicians
and certified nurse midwives to
inform pregnant women of any
drugs expected to be used during
pregnancy and the possible effects
thereof
Active Opposition
Assembly: CHHS
In committee
A- 1 1 1 6
Patera
To permit licensed psychologists
to certify disability under the
‘Temporary Disability Benefits
Law”
Active Opposition
Assembly: L
In committee
A-1158
Herman
To require licensed physicians or
chiropractors to notify the Board
of Medical Examiners if they
accept Medicare assignments
Active Opposition
Assembly: HERP
In committee
A- 1 47 1
Garvin
1
A- 1479
Deverin
To require a physician to obtain,
in advance, the patient’s
authorization to perform a biopsy
or mastectomy
To provide for the licensure of
podiatric, orthopedic, and urologic
x-ray technologists
Active Opposition
Active Opposition
No Action (same
asS-515)
Senate: IHW
Assembly: HERP
Passed
Assembly; out
of committee:
2nd reading
In committee
A- 1 54 1
To provide for the licensing of
persons who practice hypnosis
and limit the practice, teaching, or
preparation of hypnosis tapes to
licensed practitioners
Active Opposition
Assembly: HERP
In committee
Senate Committee Key
IHW: Institutions, Health and Welfare
J: Judiciaiy
LIP: Labor, Industry and Professions
LPS&D: Law, Public Safety and Defense
SGF&IR&VA State Government, Federal & Interstate Relations & Veterans Affairs
Assembly Committee Key
BI: Banking and Insurance
CHHS: Corrections, Health and Human Services
HERP: Higher Education and Regulated Professions
L: Labor
>L. 81— NUMBER 10— OCTOBER 1984
831
Attendance at Board of Trustees’ Meetings: County Societies
January 1984-May 1984
Atlantic County
January 15
February 19
March 18
April 15
May 2
Bergen County
January 15
February 19
March 18
Camden County
January 15
February 19
March 18
April 15
May 2
Alan J. Simpson, M.D., President
Melvin Markowitz, M.D., Executive
Committee
William Silverman, M.D., Treasurer
John C. Baker, M.D., President-Elect
Edwin H. McKnight, M.D.
Mrs. Jo Ann Raco, Executive Director
Alan J. Simpson, M.D., President
Marc J. Crilly, M.D., President-Elect
Mare J. Crilly, M.D., President-Elect
Mare J. Crilly, M.D., President-Elect
August P. Ciell, M.D.
Booth H. Durham, M.D.
Louis L. Keeler, M.D., President
Louis L. Keeler, M.D., President
August P. Ciell, M.D.
Louis L. Keeler, M.D., President
Donald Orth, M.D.
Joseph A. Riggs, M.D.
George T. Hare, M.D.
Joseph A. Riggs, M.D.
Ralph A Skowron, M.D.
Louis L. Keeler, M.D., President
Cumberland County
January 15 L. Willis Allen, M.D., Past President
Essex County
February 19
March 18
April 15
May 2
May 6
Bernard Robins, M.D.
Carolyn W. Watson, M.D.
Carolyn W. Watson, M.D.
Carolyn W. Watson, M.D.
Mr. Arthur Ellenberger, Executive Secretary
Mr. Arthur Ellenberger, Executive Secretary
William Greifinger, M.D.
Carolyn W. Watson, M.D.
Gloucester County
April 15 Churchill L. Blakey, M.D., Secretary
Hudson County
February 19 Janet Geraghty-Deutseh, M.D.
Mrs. Adelene F. Lynch, Executive Secretary
April 15 Joseph W. Fleisher, M.D.
May 2 Charles L. Cunniff, M.D.
Mercer County
January 15 Mrs. Joey Huddy, Executive Secretary
Ms. Anne Petchel
February 19 Mrs. Joey Huddy, Executive Secretary
Ms. Anne Petchel
March 18 Michael M. Heeg, M.D.
Michael J. Larkin, M.D.
April 15 Mrs. Joey Huddy, Executive Secretary
Ms. Anne Petchel
February 19
Middlesex County
January 15 Norval F. Kemp, M.D., President-Elect
Mrs. Mary Alice Bruno, Executive Director
Norval F. Kemp, M.D., President-Elect
Norval F. Kemp, M.D., President-Elect
Mrs. Mary Alice Bruno, Executive Director
Norval F. Kemp, M.D., President-Elect
Mrs. Mary Alice Bruno, Executive Director
Robert E. Steward, M.D.. President
Mrs. Mary Alice Bruno, Executive Director
March 18
April 15
May 2
May 6
Monmouth County
February 1 9 Birute S. Preikstas, M.D.
March 18 Mrs. Patricia Klemm, Executive Secretary
Morris County
January 15
February 19
March 18
April 15
Arthur Ginsburg, M.D., President
Michael R Henderson. M.D.
Arthur Ginsburg, M.D., President
James B. Massengill, M.D.
Allan L. Gardner, M.D., President-Elect
Arthur Ginsburg, M.D., President
Ocean County
January 1 5 Michael C. DiBella. M.D., President
Edward D. Fiore, M.D., President-Elect
Passaic County
January 15 Mr. William T. McGuire, Executive Director
Gerald H. Rozan, M.D., President
February 19 David J. Blackman, M.D., President-Elect
Gerald H. Rozan, M.D., President
April 15 David J. Blackman, M.D., President-Elect
Somerset County
February 19 Albert M. Doswald, M.D., President
April 15 Albert M. Doswald, M.D., President
Union County
January 15
March 18
April 15
May 2
May 6
Frank R Romano, M.D., Past President
Mrs. Ethel Stevens, Executive Director
Frank R Romano, M.D., Past President
Mrs. Ethel Stevens, Executive Director
Frank R Romano, M.D., Past President
Frank R Romano, M.D., Past President
Mrs. Ethel Stevens, Executive Director
Frank R Romano, M.D., Past President
Warren County
February 19 Volmar A. Mereschak, M.D., President
AMA DELEGATES REPORT
Health Policy Agenda. A special reference commit-
tee was appointed to consider the 159 principles de-
veloped by the Health Policy Agenda for the American
people. These principles are broad value statements
about what should exist in the health policy area In-
stead of adopting the principles as AMA policy, the
House voted to endorse them as working principles to
help guide AMA representatives to HPA Work Groups
and Advisory Committees throughout the remainder
of the project, scheduled for completion in 1986. In its
next phase, the HPA will translate the principles into
policy recommendations and action plans.
Hospital Medical Staff Issues. The Hospital Medical
Staff Section met for two days prior to the opening of
the AMA House. Over 700 representatives were regi;
tered from virtually every state. They considered aboi
60 resolutions and submitted 18 resolutions for cor
sideration by the AMA House. Enthusiasm amor.
HMSS representatives remains high and participatio
in this policymaking process is expected to increas
The goal is to have every hospital send a representati\
to further enhance communication between the AM
and local hospital medical staffs. The AMA House ap
proved a number of resolutions related to the organize
tion and operation of the medical staff. The House
• Supported the medical staff s authority to approVj
or disapprove all amendments to medical staff bylaw:
• Supported the idea that hospital governing board
cannot unilaterally change medical staff bylaws.
• Asked the AMA to prepare and distribute a doci
832
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Attendance at Board of Trustees' Meetings: Specialty Societies,
Academy of Medicine of New Jersey, and Auxiliary
January 1984-May 1984
'
Jew Jersey Allergy Society
February 19 Clement Maecia, M.D., President-Elect
lew Jersey State Society of Anesthesiologists
March 18 Stanley Bresticker, M.D.
April 15 Stanley Bresticker, M.D.
lew Jersey Chapter, American College of Emergency
Physicians
January 1 5 Rudolf E. Schwaeble, M.D.
February 1 9 Rudolf E. Schwaeble, M.D.
March 18 Rudolf E. Schwaeble, M.D.
April 15 Rudolf E. Schwaeble, M.D.
May 6 Rudolf E. Schwaeble, M.D.
lew Jersey Academy of Family Physicians
April 15 S. Thomas Carter, Jr., M.D., President-Elect
Joseph A Lieberman, III, M.D., Vice-
President
Carl F. Meier, M.D.
George L. Triebenbacher, M.D., President
May 2 George L. Triebenbacher, M.D., President
May 6 George L. Triebenbacher, M.D., President
lew Jersey Society of Internal Medicine
February 19 Frank J. Malta, M.D.
March 18 Frank J. Malta, M.D.
May 6 Frank J. Malta, M.D.
lew Jersey Association of Medical Specialty Societies
February 19 Frank J. Malta, M.D.. President
March 18 Stanley Bresticker, M.D.
Frank J. Malta, M.D., President
April 1 5 Stanley Bresticker, M.D.
May 6 Frank J. Malta, M.D., President
lew Jersey Obstetrical and Gynecological Society
January 15 John D. Franzoni, M.D.
February 19 John D. Franzoni, M.D.
April 15 John D. Franzoni, M.D.
:nt on the legal status of medical staffs.
1 Encouraged hospitals and medical staffs to make
medical staff rules available to physicians.
1 Directed the AMA to oppose any regulation that
uld mandate voting privileges for nonphysician
:mbers of the medical staff.
I Recommended that medical staffs develop bylaw
^visions that affirm the binding effect of medical
iff bylaws on the hospital governing board and the
;dical staff.
■Professional Liability. On the last day of the meet-
* the Board of Trustees submitted a report informng
; House that a special task force will be established
study professional liability. The task force is charged
th coordinating current AMA activities and focusing
;m on professional liability insurance. AMA Ex-
itive Vice-President, James H. Sammons, M.D., will
air the task force. Other members include AMA Gen-
ii Counsel, the Assistant Executive Vice-President,
d two Deputy Executive Vice-Presidents. The Board
II submit a report at the 1984 Interim Meeting.
LA-HOSPITAL MEDICAL STAFF
CTION MEETING
There will be a meeting of the AMA-Hospital Medical
jaff Section on November 29 to December 3, 1984, at
|5 Hilton Hawaiian Village, Honolulu. The meeting
New Jersey Academy of Ophthalmology and Otolaryngology
February 19 Edward P. Siegel, M.D.
New Jersey Orthopaedic Society
March 18 Bernard A Rineberg, M.D.
New Jersey Society of Pathologists
February 1 9 Lawrence Sylvia, M.D., Vice-President
New Jersey Society of Physical Medicine and Rehabilitation
Feburary 19 Robert Iskowitz, M.D., Member-at- Large
American College of Physicians — New Jersey
February 1 9 David A Willard, M.D., Liaison
April 15 David A Willard, M.D., Liaison
New Jersey Psychiatric Association
January 1 5 John C. Patterson, M.D., President
February 19 John C. Patterson, M.D., President
March 18 John C. Patterson, M.D., President
New Jersey Rheumatism Association
January 15 William E. Ryan, M.D., Liaison
Feburary 19 William E. Ryan, M.D., Liaison
March 18 William E. Ryan, M.D., Liaison
April 15 William E. Ryan, M.D., Liaison
May 6 William E. Ryan, M.D., Liaison
Academy of Medicine of New Jersey
January 1 5 Sherman Garrison, M.D.
February 19 Sherman Garrison, M.D.
Mr. Charles J. Heitzmann, Executive
Director
March 18 Sherman Garrison, M.D.
May 2 Sherman Garrison, M.D.
Medical Society of New Jersey Auxiliary
January 1 5 Mrs. Gale Wayman, President
February 19 Mrs. Gale Wayman, President
will consist of group sessions, open assembly, and pol-
icy deliberations. For more information contact the
AMA, Department of Hospital Medical Staff Services,
535 North Dearborn Street, Chicago, IL 60610 or call,
(1-312) 645-4747.
leadership conference
The Women Physicians’ Leadership Conference will
be held on October 27, 1984, from 8:30 am. to 3:00 p.m.
at the Medical Education Building, UMDNJ-Rutgers
Medical School, New Brunswick. Speakers will present
the following subjects: Organizational Skills; Time
Management; Working with Professional Colleagues:
After a Residency: and Women in Organized Medicine.
For reservations, please call (1-609) 896-1766, Ad Hoc
Committee on Women Membership, MSNJ.
HOMEBOUND PATIENT CARE
If you have a patient who is homebound with health
problems and is medically at risk. The Homebound
Communications Program sponsored by the New Jer-
sey Hospital Association, ( 1 -609) 452-9280, may be the
answer to your problem. It is a fee for service, 24-hour
support network.
DEFICIT REDUCTION ACT
As you may be aware. Congress passed the "Deficit
|L. 81— NUMBER 10— OCTOBER 1984
833
Reduction Act of 1984,” and the President has signed
it. Here is a brief summaiy of provisions in this law
important to physicians.
Medicare Fee Freeze. One portion of the Act is enti-
tled the “Medicare and Medicaid Budget Reconcili-
ation Amendments of 1984.” If you treat any Medicare
beneficiaries at all, its principal effect is to pressure
you into entering a participating physician agreement
to accept assignment for all services to those patients.
Most of you will want to carefully consider signing
the agreement. It would commit you to accept as full
payment (80 percent from your Medicare carrier and
the 20 percent coinsurance portion) for each
procedure or service to any Medicare patient for a year
starting October 1, 1984, the lesser of: your 1982 “cus-
tomary charge” or the 1982 “prevailing charge” in your
region for the procedure or service. This is presumably
what you had been receiving for the year just ended
in June.
The Act provides several penalties for not “signing
up” and there is a sort of reward to encourage your
participation. First of all, each time a nonparticipating
physician “knowingly and willfully" charges a Medi-
care beneficiary a fee greater than he charged for that
procedure or service in the second quarter of 1984
(April 1 through June 30), he will be subject to a fine
(up to $2,000 per charge) and to exclusion from the
Medicare program until 1989 or later. The effect is to
“freeze” your fees to any Medicare beneficiaries you
serve.
Secondly, if you do not participate, your “customary
charge" will disregard any fee above that of the second
quarter of 1984 until at least October 1, 1986.
Finally, a directory will be published of all doctors
who agree to participate. The directory will be dis-
tributed to all Social Security offices and to senior
citizens’ organizations and a letter will be sent to all
Medicare beneficiaries about the directory. Also, a toll-
free phone number will be set up by each Medicare
carrier for Medicare beneficiaries to call for names of
participating physicians.
Your reward, of sorts, for signing up is that you may
increase your fees any time after you become a partici-
pant. While the increases would not be collectible for
Medicare patients for a year, they would increase your
profile for higher Medicare payments starting October
1, 1985. And they would presumably be collectible from
non-Medicare patients and insurers in the normal
manner.
You need to consider the reduction in your income
if you participate, but you also should consider tl
effect on your standing in your market if you are ij
publicized as a participant.
In all events, you should note that the customary a |
prevailing charges, which limit Medicare’s payment i
your procedures and services, are frozen (which h
determined what Medicare would pay in the year ji
ended, June 30, 1984) until October 1, 1985.
On the basis of our initial study of this Act, c
advice to doctors who treat Medicare beneficiaries
1 ) consider carefully whether or not to sign the parti
pation agreement by which you would accept assij
ment for all procedures and services you provide
Medicare patients; and 2) do not increase your fees
Medicare beneficaries until October 1, 1985, ab(
their second quarter, 1984 level unless you sign sui
an agreement. The higher charge in mid-July woi
apparently be a violation even if you sign the agr,
ment in August or September when it becomes av;
able!
Tax Law Changes. This new Act also contains
voluminous portion entitled the ‘Tax Reform Act
1984.” While there are numerous changes affectinj
wide range of provisions, here is a list of the items
most concern to our clients: 1 ) automobiles’ busin<
write-offs were reduced, but not as adversely as we h
expected; 2) home computers’ write-offs were limit
3) recordkeeping becomes required for business <
duction of automobiles and home computers;
cafeteria plans have new rules and will need your
tention; 5) tuition benefits for medical and den
school faculty may be affected seriously; 6) VEB1
(“voluntary employees’ beneficiary organization
probably will lose their appeal; and 7) interest-fi
loans from your corporation to you also are seriou
affected.
Retirement Plan Project. You should have receiv
information about The Health Care Group retiremf
plans drafted to satisfy the 1984 TEFRA requiremen
The fees for these plans are considerably less th
“traditional” fees for individually designed plans, aj
contain all the provisions considered so important
professional health care providers. Call their toll-fij
number, (1-800) 441-0737, or write to receive me
information and take advantage of this special (
portunity.
FINI
“Envy eats nothing but its own heart.”
834
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
I
BALANCED
CALCIUM
jOw incidence of side effects
IAEDIZEM® (diltiazem HC1)
iroduces an incidence of adverse
eactions not greater than that
^ported with placebo therapy,
hus contributing to the patient’s
ense of well-being.
irdizem is indicated in the treatment of angina pectoris due to
ronaiy artery spasm and in the management of chronic stable
igina (classic effort-associated angina) in patients who cannot
jlerate therapy with beta-blockers and/or nitrates or who reman
mptomatic despite adequate doses of these agents.
sferences:
Strauss WE, McIntyre KM, Paris! AP, et al: Safety and efficacy
of diltiazem hydrochloride for the treatment of stable angina
pectoris: Report of a cooperative clinical trial. Am J Cardiol
49:560-566, 1982.
Pool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise-
inducible chronic stable angina with diltiazem: Effect on treadmill
exercise. Chest 78 (July suppl):234-238, 1980.
Reduces angina attack frequency*
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test,2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (P<.005).
CARDIZEM
(diltiazem HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
ft
Please see full prescribing information on following page.
2/84
PROFESSIONAL USE INFORMATION
cardizem
(dilhazem HCI)
30 mg and 60 mg tablets
DESCRIPTION
CARDIZEM*1 (diltiazem hydrochloride) is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist). Chemically,
diltiazem hydrochloride is 1 ,5-Benzothiazepin-4(5H)one,3-(acetyloxy)
-5-[2-(dimethylamino)ethyl ]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+) -cis-.The chemical structure is:
CH2CH2N(CH3)2
Diltiazem hydrochloride is a white to ott-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform.
It has a molecular weight of 450.98. Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administration.
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle.
Mechanisms of Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovine-induced cor-
onary artery spasm are inhibited by CARDIZEM.
2. Exertional Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect. The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases in peripheral resistance.
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrioventricu-
lar conduction in isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate-blood pressure product for any given work load.
Studies to date, primarily in patients with good ventricular function,
have not revealed evidence of a negative inotropic effect; cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
of diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater than first-degree
AV block. Diltiazem-associated prolongation of the AH interval is not
more pronounced in patients with first-degree heart block. In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine. In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins. Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxin, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration. The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours. Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem. Therapeutic blood levels of
CARDIZEM appear to be in the range of 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given; a 120-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem,
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment of spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM has been effective in controlled trials in
reducing angina frequency and increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a functioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1 Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome. This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0.48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2 Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited. Caution should
be exercised when using the drug in such patients.
3. Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4. Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals. The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued. In dogs,
doses ol 20 mg/kg were also associated with hepatic changes;
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated. Available data are not sufficient, however, to predict
the effects of concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities. In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21-month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests No intrinsic effect on fertility was observed
in rats
Pregnancy. Category C Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women; therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded.
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition. In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are: edema (2.4%),
headache (2.1%), nausea (1.9%), dizziness (1.5%),
asthenia (1.2%), AV block (1.1%). In addition, the fol
were reported infrequently (less than 1%) with the ordi
tion corresponding to the relative frequency of occuri
Cardiovascular
Nervous System:
Gastrointestinal:
Dermatologic:
Other:
Flushing, arrhythmia, hypotens
dia, palpitations, congestive
syncope
Paresthesia, nervousness,
tremor, insomnia, hallucinations
Constipation, dyspepsia, diarrl
mild elevations of alkaline phosp
SGPT, and LDH.
Pruritus, petechiae, urticaria, pt
Polyuria, nocturia.
The following additional experiences have been no
A patient with Prinzmetal's angina experiencim
vasospastic angina developed periods of transient
asystole approximately five hours after receiving a
dose of CARDIZEM
The following postmarketing events have been i
quently in patients receiving CARDIZEM: erythema m
kopenia, and extreme elevations of alkaline phospl
SGPT, LDH, and CPK. However, a definitive cause and i
these events and CARDIZEM therapy is yet to be esl
OVERDOSAGE OR EXAGGERATED RESPI
Overdosage experience with oral diltiazem has
Single oral doses of 300 mg of CARDIZEM have been
by healthy volunteers. In the event of overdosage c
response, appropriate supportive measures should b
addition to gastric lavage. The following measures may
Bradycardia
High-Degree AV
Block
Cardiac Failure
Hypotension
Administer atropine (0.60 to 1.
is no response to vagal blocka
isoproterenol cautiously.
Treat as for bradycardia abov
degree AV block should be tre
diac pacing.
Administer inotropic agents (
dopamine, or dobutamine) and
Vasopressors (eg, dopamine
bitartrate).
Actual treatment and dosage should depend on the
clinical situation and the judgment and experience
physician
The oral/LD50's in mice and rats range from 415
and from 560 to 810 mg/kg, respectively. The intrave
these species were 60 and 38 mg/kg, respectively. T
dogs is considered to be in excess of 50 mg/kg, whil
seen in monkeys at 360 mg/kg. The toxic dose in mar
but blood levels in excess of 800 ng/ml have not be
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atherosc
nary Artery Disease or Angina Pectoris at Rest
nary Artery Spasm. Dosage must be adjusted to
needs. Starting with 30 mg four times daily, before
bedtime, dosage should be increased gradually (gi
doses three or four times daily) at one- to two-day
optimum response is obtained. Although individual
respond to any dosage level, the average optimum
appears to be 180 to 240 mg/day. There are no availabl
ing dosage requirements in patients with impaired re
function If the drug must be used in such patients, titr
carried out with particular caution.
Concomitant Use With Other Antianginal Ag
1 . Sublingual NTG may be taken as required
anginal attacks during CARDIZEM therapy.
2 Prophylactic Nitrate Therapy -CARDIZEM
coadministered with short- and long-acting nitr
have been no controlled studies to evaluate
effectiveness of this combination.
3. Beta-blockers. (See WARNINGS and PRECAUT
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles
0088-1771-47) and in Unit Dose Identification Paks
0088-1 771-49). Each green tablet is engraved with U
side and 1771 engraved on the other. CARDIZEM
tablets are supplied in bottles of 100 (NDC 0088-1772
Dose Identification Paks of 100 (NDC 0088-1772-4!
tablet is engraved with MARION on one side and 177
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES. INC
KANSAS CITY, MISSOURI 64137
ROFESSIONAL LIABILITY
OMMENTARY*
The Costs of
Medical Care
j
DRG Care: Estate of Deceased
Physician; Informed Consent Medical
Suit; Where Litigation Spawns; Did You
Know
rospective pricing for care
rendered to Medicare patients
in hospitals will heighten
ilpractice risk, speakers emphasized at a recent
irida seminar of the American Hospital Association’s
ciety for Risk Management. Pressures to reduce
gth of stay, cut back on tests, and substitute less
jensive diagnostic and therapeutic procedures
lid depress existing standards of care, said Monte
Jahnke, J.D., of the Detroit firm of Kerr, Russell, and
her. Physicians “have a sense of the standard of care
it applies to a given class of treatment,” said the
troit attorney. “That standard . . . has been . . . uni-
m: what you did for the average appendectomy pa-
nt was pretty well what you do for the next one. But
der the DRG/Medicare system, there might be a
idency to reduce standards to reflect the extent of
vices possible under the new fiscal restraints. That
ild create differential expectations between Medi-
e and non-Medicare services, stimulating liability
k Wherever you have non-Medicare patients getting
e standard of care and Medicare patients receiving
haps somewhat less, there is a liability potential.”
rriction between hospitals seeking to discharge pa-
nts expeditiously and physicians holding out for a
iger length of stay undoubtedly will result, the at-
ney said. He noted one case in which a jury awarded
00,000 to a patient whose leg had to be amputated
er the utilization review nurse insisted on discharg-
1:5 her four days earlier than her physician wanted
r to be released.
II;
l
I
L. 81— NUMBER 10-OCTOBER 1984
Jahnke said that since what a physician writes down
as the appropriate diagnosis will determine how much
a hospital will get paid under DRGs, the medical record
now becomes “the centerpiece for reimbursement.”
That means the record also becomes even more critical
in documenting the care that is given.
Not every suspected coronaiy patient needs to be
placed in an intensive or coronaiy care bed, where
costs are “tremendous,” Jahnke admitted, but Michael
Azarra, president of Valley Hospital, Ridgewood, point-
ed out that keeping people out of facilities they don’t
really need is important, “The flip side ... is that if you
have guessed wrong, you have got a liability problem.”
( Medical Liability Monitor, Vol. 9, No. 3, March 27,
1984)
PATIENT CAN SUE ESTATE OF DECEASED
PHYSICIAN
A deceased physician’s estate can be reopened after
probate and subjected to a medical malpractice action
based on a newly discovered injury, an Oklahoma ap-
pellate court ruled.
The patient had extensive gynecological surgery in
November 1967. After the surgery, she had kidney
trouble and high blood pressure. Her operating phy-
sician allegedly made no effort to determine the cause.
He died on May 13, 1975. His estate was probated and
closed several months later. In October 1978, the pa-
tient’s condition was diagnosed as a hydronephrotic
kidney caused by the improper tying off of the ureter
during the 1967 surgery. Removal of the kidney re-
lieved her symptoms.
The patient filed suit to have the physician’s estate
reopened. A trial court denied her request, but the
appellate court reversed. The court noted that an estate
could be reopened by a person who had a claim based
on a contract if he had a legal excuse for not filing a
claim during the original probate of the estate. There
was no reason why the malpractice claimant should
have less rights since her claim did not arise until after
the physician’s death, the court said. The fact that
there might exist some question concerning the collec-
tability of a judgment in the future does not preclude
opening the estate, the court said — Gates v Baum, 673
P.2d 519 (Okla Ct. of App., Sept. 6, 1983; cert, denied,
Okla Sup. Ct., December 13, 1983). (The Citation, Vol.
49, No. 4, June 1, 1984)
$1.4 MILLION AWARD IN INFORMED CONSENT
MEDICAL SUIT
Ruling that a Bronx woman did not get a clear expla-
nation from her doctor of all the risks of a hys-
terectomy, a State Supreme Court juiy has ordered the
doctor to pay her $1,490,500 because he failed to get
informed consent, the woman’s lawyer said yesterday.
The 47-year-old woman contended that an operation
performed in 1977 by the defendant physician resulted
in the loss of her health and job and made her totally
dependent on others. She had worked for the city's
*This item from the Department of Professional Liability Con-
trol, MSNJ. was prepared by James E. George, M.D., J.D., and
A. Ronald Rouse who are, respectively, Director of the Depart-
ment and Director of Special Projects.
837
Department of Social Services and was earning
$12,500 a. year. A Bronx jury of three men and three
women said they found no malpractice or professional
negligence by the defendant physician, a gynecologist.
But they ruled that he had failed to make the plaintiff
aware enough of the possible alternatives and out-
comes to obtain her informed consent to perform the
operation. ( The New York Times, February 22, 1984)
MALPRACTICE: WHERE LITIGATION SPAWNS
It is no surprise that most medical malpractice ac-
tions against physicians stem from incidents in hospi-
tals (Table); only one in five originates in offices. But
a current study by a leading liability insurer identifies
a new trouble spot: ambulatoiy surgicenters. Though
such claims account for less than 1 percent of those
filed, they rank fourth in average cost per claim. ( Medi-
cal Economics, May 28, 1984)
DID YOU KNOW . . .
Two in five doctors surveyed recently by the AMA say
they’re ordering more diagnostic tests than they did
five years ago, and nearly half have increased referrals
to other physicians? The AMA estimates that the an-
nual tab for defensive medicine has grown to $15.1
billion, more than the total malpractice judgments
against physicians last year. (Medical Economics,
April 2, 1984)
Florida’s physician-owned malpractice insurer suf-
fered a net operating loss of $8.5 million last year, a
precipitious drop after the $4.6 million it lost in 1982
and the relatively modest deficit of $113,000 in 1981?
As a result, physicians are getting socked with a 30
percent increase in premiums for the third year in a
row. The average cost of the cases settled by the insurer
in 1983 was a whopping $198,000. ( Medical Econ-
omics, April 2, 1984)
I
TABLE
Where Malpractice Claims Are Most Apt to Arise*
Location
Percentage
Average coi
$35,324
Hospital operating room
32.3
Physician’s office
18.0
25,260
Hospital emergency room
12.3
24,836
Hospital patient-care area
11.8
37,565
Hospital obstetrics units
8.2
64,364
Clinic
7.9
21,053
Hospital — other areas
5.3%
23,685
Hospital outpatient
surgery
1.0
14,815
Surgicenters
0.8
29,334
Other locations
2.4
‘Based on claims filed in 1983. Source: St. Paul Fire ai
Marine Insurance Co.
Insurers in Wisconsin want to increase liabi
premiums by an average 50 percent this year? If
increases are approved, premiums for neurosurge<
would jump from $17,295 a year to $25,096; ob/g
from $9,431 to $16,730; and gps/fps, the lowest r
category, from $1,528 to $2,323 ayear? The state m(
cal society is countering by backing a malpractice
form plan that includes sanctions against “repeat
fenders,” forcing carriers to prepare adequate defen
for physicians, a cap on pain and suffering awards,
restructuring of award payments, and the eliminat
of duplicate compensation. (Medical Economics, A]
16, 1984)
838
THE JOURNAL OF THE MEDICAL SOCIETY OF
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)L. 81— NUMBER 10— OCTOBER 1984
839
Consider the
causative organisms...
jl
250-mg Pulvulest.i.d.
offers effectiveness against
the major causes of bacterial bronchitis
H. influenzae, H. influenzae, S. pneumoniae, S. pyogenes
(ampicillin-susceptible) (ampicillin-resistant)
Brief Summary Consult the package literature for prescribing
information
Indications and Usage: Ceclor" (cefaclor, Lilly) is indicated in the
treatment of the following infections when caused by susceptible
strains of the designated microorganisms
Lower respiratory infections, including pneumonia caused by
Streptococcus pneumoniae (Diplococcus pneumoniae). Haemoph-
ilus influenzae, and S pyogenes (group A beta-hemolytic
streptococci)
Appropriate culture and susceptibility studies should be
performed to determine susceptibility of the causative organism
to Ceclor
Contraindication: Ceclor is contraindicated in patients with known
allergy to the cephalosporin group of antibiotics.
Warnings: IN PENICILLIN-SENSITIVE PATIENTS, CEPHALO-
SPORIN ANTIBIOTICS SHOULD BE ADMINISTERED CAUTIOUSLY
THERE IS CLINICAL AND LABORATORY EVIDENCE OF PARTIAL
CROSS-ALLERGENICITY OF THE PENICILLINS AND THE
CEPHALOSPORINS, AND THERE ARE INSTANCES IN WHICH
PATIENTS HAVE HAD REACTIONS, INCLUDING ANAPHYLAXIS,
TO BOTH DRUG CLASSES
Antibiotics, including Ceclor, should be administered cautiously
to any patient who has demonstrated some form of allergy,
particularly to drugs.
Pseudomembranous colitis has been reported with virtually all
broad-spectrum antibiotics (including macrolides, semisynthetic
penicillins, and cephalosporins); therefore, it is important to
consider its diagnosis in patients who develop diarrhea in
association with the use of antibiotics Such colitis may range in
severity from mild to life-threatening
Treatment with broad-spectrum antibiotics alters the normal
flora of the colon and may permit overgrowth of Clostridia. Studies
indicate that a toxin produced by Clostridium difficile is one
primary cause of antibiotic-associated colitis.
Mild cases of pseudomembranous colitis usually respond to
drug discontinuance alone In moderate to severe cases, manage-
ment should include sigmoidoscopy, appropriate bacteriologic
studies, and fluid, electrolyte, and protein supplementation.
When the colitis does not improve after the drug has been
discontinued, or when it is severe, oral vancomycin is the drug
of choice for antibiotic-associated pseudomembranous colitis
produced by C. difficile Other causes of colitis should be
ruled out.
Precautions General Precautions — If an allergic reaction to
Ceclor" (cefaclor, Lilly) occurs, the drug should be discontinued,
and, if necessary, the patient should be treated with appropriate
agents, eg, pressor amines, antihistamines, or corticosteroids.
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms Careful observation of the patient is
essential If superinfection occurs during therapy, appropriate
measures should be taken
Positive direct Coombs' tests have been reported during treat-
ment with the cephalosporin antibiotics In hematologic studies
or in transfusion cross-matching procedures when antiglobulin
tests are performed on the minor side or in Coombs' testing of
newborns whose mothers have received cephalosporin antibiotics
before parturition, it should be recognized that a positive
Coombs' test may be due to the drug
Ceclor should be administered with caution in the presence of
markedly impaired renal function Under such conditions, careful
clinical observation and laboratory studies should be made
because safe dosage may be lower than that usually recommended
As a result of administration of Ceclor, a false-positive reaction
for glucose in the urine may occur This has been observed with
Benedict's and Fehling's solutions and also with Clinitest"
tablets but not with Tes-Tape* (Glucose Enzymatic Test Strip,
USP, Lilly)
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history of gastrointestinal disease, particularly
colitis.
Usage in Pregnancy - Pregnancy Category B - Reproduction
studies have been performed in mice and rats at doses up to 12
times the human dose and in ferrets given three times the maximum
human dose and have revealed no evidence of impaired fertility
or harm to the fetus due to Ceclor " (cefaclor. Lilly). There are,
however, no adequate and well-controlled studies in pregnant
women Because animal reproduction studies are not always
predictive of human response, this drug should be used during
pregnancy only if clearly needed.
Nursing Mothers - Small amounts of Ceclor have been detected
in mother's milk following administration of single 500-mg doses
Average levels were 0 18, 0.20, 0.21, and 0.16 mcg/ml at two,
three, four, and five hours respectively. Trace amounts were
detected at one hour The effect on nursing infants is not known
Caution should be exercised when Ceclor is- administered to a
nursing woman
Usage in Children - Safety and effectiveness of this product for
use in infants less than one month of age have not been established
Adverse Reactions Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2 5 percent of
patients and include diarrhea (1 in 70).
Symptoms of pseudomembranous colitis may appear either
during or after antibiotic treatment Nausea and vomiting have
been reported rarely
Hypersensitivity reactions have been reported in about 1 5
percent of patients and include morbiliform eruptions (1 in 100)
Pruritus, urticaria, and positive Coombs' tests each occur in less
than 1 in 200 patients Cases of serum-sickness-like reactions
(erythema multiforme or the above skin manifestations accompanied
by arthritis/arthralgia and, frequently, fever) have been reported
These reactions are apparently due to hypersensitivity and have
usually occurred during or following a second course of therapy
with Ceclor Such reactions have been reported more frequently
in children than in adults Signs and symptoms usually occur a few
days after initiation of therapy and subside within a few days
after cessation of therapy No serious sequelae have been reported
Antihistamines and corticosteroids appear to enhance resolution
of the syndrome
Cases of anaphylaxis have been reported, half of which have
occurred in patients with a history of penicillin allerg
Other effects considered related to therapy includi
eosinophilia (1 in 50 patients) and genital pruritus or
(less than 1 in 100 patients).
Causal Relationship Uncertain - Transitory abnorn
clinical laboratory test results have been reported. All]
were of uncertain etiology, they are listed below to si
alerting information for the physician
Hepatic - Slight elevations in SGOT. SGPT, or alk?
phosphatase values (1 in 40)
Hematopoietic - transient fluctuations in leukocyi
predominantly lymphocytosis occurring in infants and*
children (1 in 40)
Renal- Slight elevations in BUN or serum creatinine
1 in 500) or abnormal urinalysis (less than 1 in 200).
Note Ceclor" (cefaclor, Lilly) is contraindicated in p;
with known allergy to the cephalosporins and should
cautiously to penicillin-allergic patients
Penicillin is the usual drug of choice in the treatin' ]
prevention of streptococcal infections, including the i
of rheumatic fever See prescribing information
©1984, ELI LILLY AND COMPANY
Additional information available
the profession on request from
Eli Lilly and Company.
Indianapolis. Indiana 46285
Eli Lilly Industries, Inc
Carolina, Puerto Rico 00630
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
840
Editorial
The Rising Cost of
Medical Care
The cost of health care has preoccupied
individual physicians, organized
medicine, government, labor,
management, health economists, and
patients. This complex issue will be
discussed in future editorials.
At their March 18, 1984, meeting,
the Board of Trustees approved
a recommendation of the Coun-
|l on Public Relations to direct the Editor of The
h> umal to write (or have written) a series of editorials
'll that subject which has preoccupied individual phy-
Jans, organized medicine, government, labor, man-
(ement, health economists, and, above all, patients—
e cost of health care to the individual and to the
lition. Grappling with this topic hypothetically and
agmatically is a bit like explaining a Jackson Pollock
■ istract painting or a Milton Babbitt composition
ised on the 12-tone musical scale to a group of
terested but uninformed sixth graders. Or, it may be
Skened to the proverbial elephant (health care cost)
1 ing described by six blind men (medicine, govem-
ent, consumers, management, labor, and econo-
ists) (Figure).
At the outset, one must admit that the subject is
1 mplex and growing. Simplistic solutions such as fix-
g physician fees, prospective hospital payment under
Diagnosis Related Group (DRG) scheme, rationing of
■alth care, interdicting the availability and utilization
• expensive and complex technological equipment, or
en a combination of these and other unthought of
•tions, are not likely to unfurrow the nation’s brow,
ke the shadow target of the boxer during a condition-
ig workout, the subject keeps changing, bobbing, and
)L. 81— NUMBER 10— OCTOBER 1984
weaving, growing larger and then smaller; the shadowy
opponent always stays on his feet until the lights go
off. It is unalterably true that the health care cost
elephant is not going to go away, and that the six blind
men never may be able to “see” the whole beast. Never-
theless, by mandate and in an attempt to be relevant,
The Journal will take a crack at the subject.
We readily admit that these pieces are being written
for the wrong audience. Most physicians will read
them and say, “I know that!” and they probably will
know “that” and a lot more. The patient— the “con-
sumer” as the economist likes to call him, or the
“client” as the social worker says — should be reading
these editorials. Short of that, practitioners may or-
ganize their ideas and discuss them calmly and ration-
ally with their patients, their friends, their state and
national representatives (when possible), and their
own providers of goods and services.
Why are medical costs rising? That is not a difficult
question to answer, as long as one can provide a long
and intertwining answer. Do medical costs differ from
the costs of bread, computers, a ticket to the World
Series, or a Michael Jackson concert? You’re dam
tootin’ they do!
There are many factors which one can tick off and
I intend to do just that, but one I shall not dwell on
is fundamental and that is the spirit of freedom of
choice. Americans do not like to be told they can’t have
this, or they must do that. They do not like to queue
up for anything (especially left-over cheese that their
government is tiying to pawn off on them for a few
votes). Scientists and biomedical engineers do not
want to be told they should not dream up a better
mousetrap. Physicians hate being told they must
prescribe a generic drug- especially when its pharma-
cokinetics are unclear. American politicians with cor-
onary artery disease want that quadruple bypass, but
grumble that 170,000 such operations were performed
last year in the United States at a cost of more than
$3 billion. Who is to get the bypass, the organ trans-
plant, the ICU care, the pacemaker, or the hundreds
of other expensive treatments, devices, and studies
which are commonplace in this America?
The definable contributing forces to health care cost
can be considered as a kind of laundiy list, which
Figure — The health care cost elephant. Credit: JAK/’84.
841
obviously needs intensive dissection in future edi-
torials (these will not be listed in order of importance):
1. Inflation. Inflation is the reason a good 5<£ cup
of coffee now costs 50<t. It is a complex economic sub-
ject which U.S. presidents like to blame on previous
administrations. It has to do with undue expansion of
currency by the issuing of paper money, which govern-
ments then like to take back by taxation and borrow-
ing at the expense of future generations. It is as-
sociated with runaway prices and runaway credit. Is-
rael’s three-figure inflation is among the highest in the
world, but high single-digit inflation in the United
States is not a comfort to those on fixed incomes,
whether they are pensioners or hospitals on DRG.
2. Technology. Science and research are the quest
for truth. Biomedical engineers, basic scientists, and
clinical researchers are bound to make discoveries
which enhance the potential for a better life. America
is the world frontier for the development of remarkable
equipment, pharmaceuticals, and other technological
advances — and should remain so.
3. Government Factors. The contribution of gov-
ernment dollars to medical and scientific education
and research represents a major investment. However,
the cost of government regulation of the health indus-
try also is a preponderant part of the nation’s health
care costs. This cannot be overemphasized.
4. Consumer Factors. The patient, as well as the
ordinary citizen who simply is growing older, con-
tributes a great deal to the nation’s medical costs.
Intrinsic diseases, such as diabetes, cause an obliga-
tory expenditure of treatment dollars, but add the fac-
tor of lost wages. The cost of drugs and the excessive
demand for services are major factors which, to some
extent, are patient controlled.
5. Professional Factors. The physician has been
labeled the “gatekeeper” for health care services, and
thus has been identified as a source of the problem
of high cost. Fees are obvious, but the peripheral costs
which include professional liability expenditures and
continuing medical education also must be factored.
Not to be forgotten are costs engendered outside the
physician’s control by paraprofessionals and others
6. Lifestyle. It is unquestionable that America',
modem lifestyle possibly is the largest factor. Tobaccc
alcohol, and substance abuse, directly and indirectl;
eat up many billions of dollars. Failure to use aut
seatbelts, the simple dominance of the auto and th
motorcycle in American life, the sedentary existeno
and nutrition abuse leading to obesity must be fa<
tored in as well.
7. Psychosocial Factors. Americans believe they ai
entitled to the good life, and this includes good healtl
Television has shown that the 28-minute cure (leavin
time for commercials) should be the norm for mos
serious diseases, and much less for ordinary ones. Th
roles of stress to the ordinary citizen and the costs c
crime (murder, suicide, rape, and physical abuse to se
and others) and other psychological and social facto:
are large.
8. Hospital, Nursing Home, and Home Care Cost
What do you do with the sick, the elderly, those wh
cannot care for themselves, or who need care whic
only can be provided in an institutional setting? Th!
answers are obvious, but that does not mitigate th
costs, which are gigantic and growing. Simple, th
solution is not — for the hospital is the recipient of th
problems engendered by all of the above.
9. Public Health Costs. The State Department c
Health and Human Services — and their federal healt
agency equivalents— are responsible for a great deal (
the health dollar expenditure. A close look at thes
areas is as essential as all the rest.
So what can be said about health care costs? Is th
patient responsible? Yes. Is government responsible
Yes. Is the physician the gatekeeper? Yes. Is lifesty!
a factor? Yes. Is science responsible? Yes. Is inflatio
a problem? Absolutely. Are hospitals, nursing home:
and psychological and social factors contributory? Cei
tainly.
We will explore each of these areas, which has bee|
touched on ever so briefly, in future editorials. In th,
meantime, as the man used to say, don’t touch thcj l
dial! AT
842
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
IDITORIAL
Dr. John F. Kustrup
1907-1984
John Francis Kustrup, Sr., M.D., was
the 1 7 6th president of the Medicial
Society of New Jersey. He died on July
5, 1984.
;
j
We have lost a fine surgeon, a con-
cerned and caring physician, a
humanitarian, and a good
i nd. John Kustrup was a household name among
i irge segment of Mercer County and central New
I sey residents who were his devoted patients, and
ijo spoke of him with near- reverence,
til soft voice, a contagious smile, a gentle good humor,
ul twinkling eyes were his trademarks. Colleagues
s] ke with great respect and affection for John
< drup.
jom in Trenton in 1907, John studied medicine at
j >rgetown University Medical School and graduated
u930. He interned at St. Francis Hospital where he
ar served as director and chief of surgery. He fulfilled
i argical residency at the Delaware Memorial Hospi-
c Wilmington, and did graduate work at the Gradu-
School of Medicine, University of Pennsylvania
t his peak. Dr. Kustrup was elected President of
■1 NJ in 1968, after having served the Mercer County
iical Society, the Medical Society of New Jersey, and
i 81— NUMBER 10— OCTOBER 1984
the AMA in numerous important capacities including
Fellow, Officer, and AMA Delegate. His professional ac-
complishments included fellowship in the American
College of Surgeons and the International College of
Surgeons, and multiple hospital appointments.
Dr. Kustrup enjoyed telling anecdotes about himself
and his local colleagues who competed for house calls
in the impecunious days of the Depression, which were
so difficult for new medical graduates. His greatest
prides were his two sons, John F. Kustrup, Jr., a sur-
geon, and William J. Kustrup, an ophthalmologist, both
of whom are active members of the Mercer County and
State Medical Societies.
John F. Kustrup is survived by his wife, the former
Eva H. Williams, his daughter, Elizabeth Kustrup
Sheahan, and his two sons. He was honored with
MSNJ’s Golden Merit Award for 50 years of medical
service to his community in 1980.
Fine physicians like John F. Kustrup do not die, for
they live on in the hearts of those they leave behind.
AK
843
Protection
th Benefits
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA— either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets—
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
hieve optimal control. INDERAL LA should not be used in congestive
eart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING
CAPSULES
The appearance ol
INDERAl I A
Ayerst
capsules is a registered
trademark ot
Ayerst L aboratories
ONCE-DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE ,
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERAL LA -i
LONG ACTING
CAPSULES
£
s
V
V
v
80
120
160
mg
mg
mg
I
i
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION. SEE PACKAGE CIRCULAR )
INDERAL LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rateot absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there Is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it read|usts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients.
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic; ,
pressure and systolic election period The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity.
In dosages greater than required for beta blockade, INDERAL also exerts a quimdine-like
or anesthetic-like membrane action which affects the cardiac action potential The signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the plat vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For" example!' "in patients with Severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients sub|ect to bronchospasm.
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
,i
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking tl
prior to ma|or surgery is controversial. It should be noted, however, that the impaired a]
the heart to respond to reflex adrenergic stimuli may augment the risks of general ane|
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor oj,s
receptor agonists and its effects can be reversed by administration of such agentr
dobutamme or isoproterenol. However, such patients may be subject to protracted
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported
beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent I
pearance of certain premonitory signs and symptoms (pulse rate and pressure cham;
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be
difficult to adjust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyre!
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of syrr
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have
reported in which, after propranolol, the tachycardia was replaced by a severe bradyj
requiring a demand pacemaker In one case this resulted after an initial dose of I
propranolol.
PRECAUTIONS. General: Propranolol should be used with caution in patients with im|
hepatic or renal function. INDERAL is not indicated for the treatment of hyperti
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure P
should be told that INDERAL may interfere with the glaucoma screening test. Withdraw
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests . Elevated blood urea levels in patients with severe heart di:
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered. The added catechol
blocking action may produce an excessive reduction of resting sympathetic nervous s
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, ororthi
hypotension.
Carcinogenesis, Mutagenesis. Impairment of Fertility: Long-term studies in animal;,
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stur
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sign
drug-induced toxicity There were no drug-related tumorigenlc effects at any of the d
fevefs Reproductive studies in animals did not show any impairment of fertility th
attributable to the drug
Pregnancy Pregnancy Category C, INDERAL has been shown to be embryotc
animal studies at doses about 10 times greater than the maximum recommended human
There are no adequate and well-controtted studies in pregnant women INDERAL ;
be used during pregnancy only if the potential benefit justifies the potential risk to the
Nursing Mothers INDERAL is excreted in human milk. Caution should be exercised
INDERAL is,.administered to a nursing woman
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient anc|
rarely required the withdrawal of therapy.
Cardiovascular: bradycardia, congestive heart failure, intensification of AV block,
tension; paresthesia of hands; thrombocytopenic purpura, arterial insufficiency, usually
Raynaud type
Central Nervous System lightheadedness; mental depression manifested by msc
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia, ■»
disturbances, hallucinations; an acute reversible syndrome characterized by disorientatlm
time and place, short-term memory loss, emotional lability slightly clouded sensoriurrlKt
decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, dials,
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with a[Kt|
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytolic
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has jin
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male j)-,
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous real's
involving the skin, serous membranes and coniunctivae reported for a beta blocker (praijf-
have not been associated with propranolol
c:
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochlorid
sustained-release capsule for administration once daily. If patients are switched from IND
tablets to INDERAL LA capsules, care should be taken to assure that the desired theraj
effect is maintained INDERAL LA should not be considered a simple mg for mg substiti
INDERAL INDERAL LA has different kinetics and produces lower blood levels. Retitratioi
be necessary especially to maintain effectiveness at the end of the 24-hour dosing mt
HYPERTENSION — Dosage must be individualized. The usual initial dosage is 8
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage m;
increased to 120 mg once daily or higher until adequate blood-pressure control is achi.
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosagei P)
mg may be required. The time needed for full hypertensive response to a given doss 8
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDER/jP
once daily, dosage should be gradually increased at three to seven day intervals until opLj11
response is obtained. Although individual patients may respond at any dosage levelM
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the valuijo 1
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few wPl
(see WARNINGS).
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDER/p
once daily. The usual effective dose range is 160-240 mg once daily The dosage m*j
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response j*
obtained within four to six weeks after reaching the maximum dose, INDERAL LA th V;
should be discontinued It may be advisable to withdraw the drug gradually over a pen 1
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily, j j
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group aijSi
limited to permit adequate directions for use.
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboralt'
8833 1
* . AYERST LABORATORIES
MyerSlY New York, N.Y. 10017
846
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
ospital Governing
oards*
Hospital Medical Staffs
ind Their Retention of
Separate Legal Counsel
Vincent A. Maressa, j.d.
heAMA and MSNJ have recommended that
ospitcd medical staffs should retain legal
mnsel separate and distinctfrom that
itained by the hospital governing board.
I
The American Medical Associa-
tion and the Medical Society of
New Jersey have recommended
1 1 hospital medical staffs should retain legal counsel
t arate and distinct from that retained by the hospi-
sgoveming board.
awyers representing hospitals have opposed this
(cept arguing that the medical staff simply is an
o anizational extension of the governing board; and
1 1, consequently, there is no separate or self-govem-
r. medical staff. That position is not sound and does
i< withstand scrutiny. It is clear that the medical staff
n st be organized so as to be separate from the gov-
i ing board. The Joint Commission on Accreditation
'Hospitals (JCAH) standards. Medicare and Medicaid
e llations, and hospital licensing laws in New Jersey
il equire that the medical staff be organized separ-
ily
nother frequently raised issue is that a separate
n lical staff means increased corporate and tort lia-
'iy and potential for greater antitrust exposure.
V ither the staff is separate or not, its members per-
r ally will be liable only to the extent that they partici-
*i; in wrongful conduct. Hospitals gain no advantage
81— NUMBER 1 0 — OCTOBER 1984
from treating the medical staff as a nonentity. The
antitrust rule of reason concept, which would be the
general rule of law applied, would involve a study of the
particular circumstances in each case, and not
whether or not there is a separate organized staff.
Legal ethics require the attorney to present his
client’s point of view as best he can. Since the medical
staff and the governing board can have a divergent
position on any issue, separate counsel is not only
desirable, it is necessary. Retention of separate counsel
is not at all inconsistent with the mutual commitment
of the staff and governing board to quality care. Telling
medical staffs they cannot consult and retain separate
counsel is not legally sound, ignores reality, and pro-
motes confrontation. Governing boards and medical
staffs should recognize their unique and common
responsibilities in providing the best care they can.
They also should appreciate the necessity of adequate
and separate legal representation in the discharge of
those responsibilities.
*The material for this column is edited by Arthur Krosnick,
M.D., Editor of The Journal; Vincent Maressa, J.D., Executive
Director of MSNJ; and James E. George, M.D., J.D., Director
of the Department of Professional Liability.
847
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AS you made your decision to establish yourself
in New Jersey, you no doubt heard horror
stories about our professional liability insurance
problems. The legal risks we assume in this
business have grown so far out of proportion
that many commercial underwriters have been
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848
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER9
Initial Experience with In Vitro
Fertilization in New Jersey
E. Kemmann, m.d., D. Colburn, m.d., S. Pasquale, m.d., J. Nosher, m.d.,
V.T. Brandeis, m.d., A.M. Delisi, m.d., R.M. Shelden, M.D., NEW BRUNSWICK*
In vitro fertilization is a new method in the management of
previously untreatable infertility situations. The first program in
\ew Jersey became operational in 1983. Organization , patient
selection , procedures , and initial results of the early experience
pfin vitro fertilization are described.
Louise Brown, bom in England
on July 25, 1978, was the first
child conceived after fertiliza-
t n of the oocyte outside of her mother’s body.1 Subse-
cently, the technology of in vitro fertilization (IVF)
nidly evolved and expanded. The first IVF program
i the United States was initiated amidst controversy
i Norfolk, Virginia The first pregnancy in the Norfolk
pgram occurred in April 1981, and completed suc-
Cisfully in December 1981. 2 3 At the annual meeting
c the American Fertility Society in the spring of 1982,
Ip investigators from the Norfolk program, as well as
a ew physicians who had started programs elsewhere,
iborted their initial experiences. Thus, it was ap-
p rent the stage had been set to make the introduction
c IVF possible on a wider scale.
3ecause of our own experience in the use of
j£ radotropins, laparoscopy, and tissue culturing, we
srmised that IVF was feasible at our institution, and
v uld be useful for our patients.
during 1982, the program protocol was developed
ad approval of the Committee on Human Research
vs obtained; financial and logistical questions were
r olved, and members of the team attended an IVF
v rkshop in Norfolk.4 Early in 1983 construction of an
Fi'-culture room was completed and the room
e pipped. The program officially opened in May 1983.
d*e following is a report on the IVF experience during
4 remainder of 1983. The IVF program at UMDNJ-
Rutgers Medical School, Middlesex General-University
Hospital is the first and only program with known
pregnancies in New Jersey.
MATERIAL AND METHODS
Referred or interested patients are telephone
screened and placed on a list from which they are given
appointments to the screening clinic. In the screening
clinic, the fertility situation is evaluated, and the cou-
ple is presented with an explanation of the procedures
involved. Further workup (if necessary) will be done in
the screening clinic before admission to the active pro-
gram. Patients with inappropriate indication for IVF
will be so advised. In the screening clinic the couple
will meet at least one of the physicians of the program
as well as the program coordinator.
As the couple approaches the active phase of the
program, the coordinator provides further explanation
and support as needed. The coordinator leads the cou-
ple through each phase of the program. An informed
consent is signed before entering the active phase.
PATIENT SELECTION
Between May and November 1983, 27 patients were
‘From the Departments of Obstetrics and Gynecology and
Radiology, UMDNJ-Rutgers Medical School. Correspondence
may be addressed to Dr. Kemmann. UMDNJ-Rutgers Medical
School, Academic Health Science Center, CN 19, New Bruns-
wick, NJ 08903.
T. 81— NUMBER 10— OCTOBER 1984
849
TABLE 1
Patient Profile oj 27 Women Started
in Active Treatment Phase
• Married
• Tubal infertility
(post-tuboplasty/ ectopic)
• Age: range, 24 to 37; mean, 32
• Infertility: range, 35-10 years; mean, 5.5
• Male: normal semen analysis
entered into the active treatment program. Their ages
ranged from 24 to 37 (mean 32) years, and all women
had infertility due to absent or chronically damaged
tubes. Other criteria for patient selection were: 1 ) mar-
ried infertile women with no contraindication to IVF
and pregnancy; 2) age less than 38 years; and 3) ac-
ceptable semen analysis of husband ( > 1 5 x 106
sperm/ml, motility > 40 percent, morphology > 40
percent normal) (Table 1).
All patients had previous pelvic surgeiy. Screening
laparoscopies generally were not done, but the patients
either agreed or disagreed beforehand to possible
laparotomy if laparoscopy could not secure ovarian
access. Normal ovulation was not a prerequisite of in-
clusion.
TREATMENT
Induction of Ovulation. Initially, we used human
menopausal gonadotropin (hMG) alone for follicular
stimulation, but later adopted a combination regimen
of clomiphene citrate, 50 mg daily, day 2 to 6 po, com-
bined with hMG 75 I.U. intramuscularly daily (Figure
1). Thus, the first part of the induction phase was
fixed. After day 6, daily hMG was continued on an
individually adjusted basis (variable part of induction
phase). During this regimen, serum estradiol levels
(E2) and pelvic sonograms were obtained daily or every
other day to monitor follicular growth. Once the most
advanced follicle reached 16 to 18 mm in diameter, and
two or more follicles were present, hMG administration
was discontinued and 24 to 36 hours later 5,000 I.U.
of human chorionic gonadotropin (hCG) were given
intramuscularly. Patients with more than two follicles
of at least 16 mm size and without significant serum
E2 decline prior to hCG administration were sched-
uled for laparoscopy about 34 hours after hCG admin-
istration (range 28 to 36).
While the wife was receiving hMG, the husband was
treated with doxycilline 100 mg daily to reduce the
possible effect of genitourinary infections on the in
vitro ovum cultures later.
Laparoscopy. Laparoscopy usually was performed in
the morning, using standard technique with C02 in-
sufflation under general anesthesia Follicles were
aspirated using a Norfolk aspirating needle (12 gauge)
through the operating channel of a 10 mm Wolf
laparoscope. Through a second puncture, a grasping
forceps was placed to stabilize the ovary. The follicular
aspirates were collected in a culture tube trap (Falcon,
#2003, 12 x 75mm) connected to the aspirating needle
via Teflon tubing through a silicone stopper. Suction
was controlled by means of a finger valve attached to
the aspiration needle and vacuum provided from con-
E2
PQ,
700-
500-
300-
200«
100-
50-
DAY
SONAR
INDUCTION PHASE
FIXED . VARIABLE
OVULATORY
PHASE
0 0 0 0 0
rTTTTTT
LUTEAL PHASE
fhCG maintenance)
I'C'V ' ,, l l , r_r
A. 5000 hCG
J 34 hrs
B: Laparoscopy
| 48 hrs
C. Embryo -transte
0: 50 mg c c
I ; 75 i u hMG 1
Figure 1 — Scheme of treatment regimen. Medication consii
of 50 mg/day of clomiphene citrate for five days (circles) £
75 I.U. hMG/day for variable time (small arrows). hMG d-
may be modified according to estrogen response.
tinuous wall suction at 100 to 120 mm Hg; it wji
controlled by the operator. In general, after aspirati
the follicular fluid, the follicle was flushed and, sep,
ately, the needle was rinsed using Dulbecco’s PBS so
tion. Each specimen was transferred immediately
personnel in the adjacent IVF-culture room.
Embryo Recovery, Fertilization, and Culture. E
biyo culture procedures essentially were as describ
for the Norfolk program with minor modification
Stock Hams F-10 media (GIBCO, cat #430-1200) w
prepared by dissolving 9.1 gm F-10 powder in 5
redistilled, ultrapure (0.2 micron filter) water, addi
sodium bicarbonate (2.1 g, 25 mM), calcium lack
(0.245 g, 0.9 mM), and penicillin G (75 mg/1). We c
not use streptomycin in our culture media Afl
equilibration with 5 percent C02 in air (USP) for
to 15 minutes, the stock solution was adjusted to j
7.35-7.40 with HC1 or NaOH; osmolality was adjust
to 280 mmoles/kg, and filter sterilized (0.2 micro:
Culture media were stored up to two weeks at 4°(
Patient serum was obtained after administration
hCG during the ovulation induction phase and dec
tivated at 58°C for 30 minutes. Culture medium (Har
F-10) was brought to 37°C, equilibrated with 5 perce!
C02, and supplemented with 7.5 percent deactivate
serum for insemination medium (IM), and 15 perce
serum for growth medium (GM). After supplement;
tion, pH and osmolality were checked and readjusts
as needed, then resterilized with 0.2 micron filter. I
semination medium, 2.0 ml per dish, was aliquoted
an appropriate number of culture dishes (Falcc
#3037) and allowed to equilibrate in the incubator fj
16 to 20 hours prior to laparoscopy. Growth mediu
was similarly aliquoted and equilibrated after recove
of oocytes at laparoscopy.
For instrument rinse, follicular wash, and follicul
fluid dilution, we used Dulbeceo’s phosphate bufferc
saline (GIBCO, cat #450-1300). DPBS was prepared .1
per manufacturer's recommendations with addition
0.1 g calcium chloride and 75 mg penicillin G, adjustr
to pH 7.4 at 37°C, and 280 mmoles/kg, then stored
4°C. Prior to laparoscopy, DPBS was supplement)
with 10 to 15 units/ml sodium heparin, aseptica!
loaded into syringes for follicular flushing, and allowe
to equilibrate at 40 to 45°C (ambient C02 atmosphere
850
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
I jure 2A — Mature ovum. Note radial orientation of coronal
ills adjacent to zona pellucida (1), with expanded, mucified
E-a peripheral to corona (2), and the enlarged, but more
c isely arranged cumulus cells on the periphery (3). Approx -
iately 160 x after photographic enlargement.
F;ure 2B — Fertilized ovum 18.5 hours postinsemination,
bnuclei are juxtaposed, but fusion (syngamy) has not oc-
rred (1). Note primary and secondary polar bodies in the
: ivitelline space (2). Approximately 900 x after photo-
2 phic enlargement.
Jpon aspiration of the follicular contents, the trap
as removed, capped, and handed directly to culture
rsonnel in the adjacent culture facility. Time of
iij)iration was noted and the aspirate volume was ap-
nximated by comparison with a previously calibrated
[be. Contents of the trap immediately were decanted
io a warmed (38°C) culture dish (Falcon #3002) and
;:oer examined immediately or temporarily placed in
humidified 37°C incubator if examination was de-
red more than one to two minutes. The aspirate was
hmined at 10 to 40 x and oocytes immediately were
nsferred via siliconized Pasteur pipet from the
<jicular aspirate or wash to insemination medium
ip placed in the culture incubator (5 percent C02 in
h 37.3° C, 98 percent RH). Detailed examination of
F oocyte was postponed until all follicular aspirates
i i washings had been examined thoroughly and any
l|iitional oocytes transferred to insemination me-
lim.
i)ach oocyte was examined and classified as 1)
1 ovulatory (expanded cumulus and corona, Figure
2i; 2) intermediate (expanded cumulus with compact
' L. 81— NUMBER 10— OCTOBER 1984
Figure 2C — Six-cell embryo (only three blastomeres in focus)
48 hours postinsemination. Approximately 900 x after photo-
graphic enlargement.
corona); 3) immature (compact cumulus and corona);
or 4) atretic (absence of cellullar vestments and/or dis-
torted, discolored, or fragmented ooplasm). Although
this examination was subjective and often incomplete
due to poor visualization of the oocyte through the
surrounding cell vestments, no attempt was made at
this stage to remove covering cells in order to enhance
visualization.
After classification of the recovered oocyte, the hus-
band was asked to deliver a semen specimen. Semen
(1 ml) was diluted with insemination medium (2 ml)
then centrifuged at approximately 225 x g for 10
minutes at room temperature. The supernatant was
discarded, the pellet resuspended in 2 ml fresh in-
semination medium recentrifuged as above, and the
second supernatant fluid removed. Without disturbing
the sperm cell pellet, 1 ml of insemination medium was
overlayered, and the tube placed nearly horizontal in
the C02 incubator. During the ensuing incubation, the
sperm cell pellet settled out of the tube tip and spread
over the lower tube wall, forming a large surface area
for “escape” by active spermatozoa After 60 to 90 min-
utes, the insemination medium with active sperm was
collected without disturbing any residual pellet. Sperm
motility and density were determined, and aliquotes of
the washed sperm preparation diluted as needed with
insemination medium. Typically, these sperm prep-
arations demonstrated greater than the 90 percent
motility, even when initial motility was less than 40
percent. Recovered spermatozoa could be maintained
under these culture conditions at least 48 hours
without discernible decrease in motility.
Following 6 to 8 hours preincubation (up to 24
hours for immature oocytes), approximately 2 x 105
motile sperm in 50 to 100 ,ul insemination medium
were placed with each oocyte. The oocytes were in-
cubated with sperm for 12 to 16 hours, then trans-
ferred to 2 ml of growth medium previously equil-
ibrated for at least 14 hours. At this time, embiyos
were examined for polar bodies and pronuclei, the
presence of 2 pronuclei being taken as presumptive
evidence of normal spemi penetration (Figure 2B).
Subsequently, embiyos were examined daily to assess
cleavage and development.
Embryo Transfer. Embryo transfer and followup
851
were scheduled 48 to 60 hours after insemination. The
average time between laparoscopy and transfer was 56
hours. At this point successfully fertilized oocytes con-
sisted of four or more cells (Figure 2C). All transfers
were performed on an outpatient basis without
anesthesia Prior to the transfer, patients were treated
with tetracycline 250 mg q4h, but this was discon-
tinued the day after transfer. Patients were placed in
a semilithotomy position. A Norfolk transfer cannula
consisting of a 20 ga Teflon tubing with side opening
was used.5 Prior to transfer, the syringe (1 cc) and
catheter were aseptically flushed, then filled with
growth medium wrapped in sterile covering and placed
overnight in the C02 incubator. At transfer, excess
growth medium was expelled; then, 20 to 30 microliter
columns of air, growth medium, air, and growth me-
dium were aspirated into the catheter. Embiyos were
placed in the central GM column via hand-drawn glass
micropipet, and the assembled apparatus handed to
the transfer physician. The cervix was wiped with a
cotton-tipped applicator and a single-toothed
tenaculum applied. The Norfolk cannula was inserted
into the external os and the Teflon catheter was in-
serted to a premeasured distance. After gently com-
pressing the syringe plunger to expell the embryo into
the womb, the tubing was retracted and the cannula
removed. The cannula then was examined (20 to 40
x stereoscope) to ensure that the embryo had been
transferred. The patient remained in Trendelenburg
position for 4 to 6 hours and then discharged.
Post-transfer patients were seen every three days to
check serum estradiol and progesterone levels. At each
visit, 1,000 I.U. hCG were administered intramuscular-
ly (unless serum E2 level at the previous visit exceeded
500 pg/ml) starting with the day of transfer. If no
menses had occurred 16 days post-transfer, a beta-
hCG level (serum) was obtained, and positive results
were verified by subsequent presence of an in-
trauterine gestational sac on sonography.
RESULTS
Twenty-seven women were started on ovulation-in-
ducing medication for 50 treatment cycles. Of these 50,
25 treatment cycles were abandoned because follicular
development was deemed unsatisfactory by above
criteria. Four of the 27 patients never came to
laparoscopy because of inadequate follicular develop-
ment.
In 23 patients, 25 treatment cycles led to laparoscopy
and, in 3 patients, to laparotomy. Oocytes were re-
covered in 20 situations, with a mean recoveiy rate of
1.8/case. Fertilization (as per cleavage) was noted in 18
of 20 cases with a rate of 1 . 7/case. Embryo transfer was
perfonned in 18 patients. Figure 1 demonstrates rep-
resentative stages of oocyte/embiyo development in
culture.
In 16 patients, menses occurred approximately 14
days post-transfer. Two patients conceived (Table 2).
PREGNANCIES
Patient 1 (Figure 3) is a 32-year-old P0020 who had
two previous ectopic pregnancies resulting in right
salpingectomy and left salpingo-oophoreetomy.
After her last menstrual period on October 14, 1983,
a clomiphene citrate-hMG regimen was started and
TABLE 2
Result of IVF Therapy in 23 Patients
Who Underwent 25 Laparoscopies
• Laparoscopies
25
• Oocytes recovered
20 (80%)
• Transfers
18 (72%)
• Pregnancy
2 ( 8%)
Figure 3 — Treatment cycle of first patient who conceived
eles: 50 mg clomiphene citrate; small arrows: 75 I.U. hMC
5,000 I.U. hCG; B: laparoscopy; C: embiyo transfer; (P): pi
nancy test positive 16 days after transfer).
monitored by serum estradiol and sonography, h'ji
was administered on October 24, with laparoscopy 1
hours later; two oocytes were recovered. Both oocyi
were fertilized and underwent cleavage, and on Oc-
ber 27 both oocytes were transferred. The pregnau
test on November 14 was positive, and a followup soi-
gram verified presence of a single intrauterine gesf
tion.
Patient 2 is a 30-year-old P0000 with failed bilate 1
fimbrioplasty in 1979. In addition, on Sims-Huhrr
test, spermatozoa were noted to be nonmobile, anu
test for cervical sperm-antibodies (Elisa) was positii*
After her last menstrual period on November Ell
clomiphene citrate-hMG regimen was initiated aSf
monitored using E2 levels and sonograpl
Laparoscopy was performed on November 18, 1983 (jf
hours post-hCG), and one oocyte was recovered. Af
fertilization and cleavage, the embiyo was transfen
on November 21. A positive pregnancy test was (
tained December 6, 1983, verified three weeks later
sonography.
COMMENT
This report describes our first experience with
vitro fertilization (IVF) in New Jersey. Locally, the
eeption of the procedure was favorable and met
major objections. To minimize concern regardi;
“extra" fertilized egg cells, our policy is to place
fertilized, normally developing oocytes into the n
temal womb. Indeed, the reinsertion of more than o
embryo has been shown to increase the probability
establishing a pregnancy. No embryo was arbitral
abandoned. Embryos were left undisturbed during c,
ture except for minimal examination to assess develc
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
852
■nt. Initial concerns about the outcome of these “un-
tural" pregnancies largely have been alleviated by
5 experience of other IVF programs with an increas-
l number of seemingly normal pregnancy outcomes,
vertheless, further observation and caution appear
ident until sufficient experience has been attained
assess adequately the long-term implications of in
ro fertilization procedure. All patients are made
are of this issue.
patients specifically were quite receptive to the local
roduction of IVF; for many patients, travel— perhaps
leatedly— to a distant IVF center is psychologically
,j economically disadvantageous. The central lo-
ion of the IVF facilities in New Brunswick makes
possible for some patients to continue their daily
itine as they participate in the program.
'he main side effect upon participants of the IVF
igram is stress. Despite thorough and rational ex-
nations, each couple believes that they will be the
ky one who “beats the odds.” We have found it help-
to institute an ongoing counselling program, to
wide not only psychological support and education
: patients, but also to provide feedback to IVF person-
so that the programs will be sensitive to patient
i“ds.
Results of our work fall well
within those seen in the
reported IVF experience.
here are a number of points in which our program
ijers from the majority of other programs:
The Rutgers Medical School program has been
fe to enter interested patients relatively quickly into
screening process. Although some programs have
icribed waiting lists of several hundreds or even
rlusands of patients, it is apparent that many names
j waiting lists represent inactive or ineligible pa-
nts. Seriously interested patients usually can be
m within a few months.
In our program, evidence of normal ovulation was
< a prerequisite for admission. We believe that as
dents are treated with ovulation-inducing agents,
' presence of normal ovulation in unstimulated cy-
I may be of little relevance. At this time, the patients
’ h elevated FSH levels (indicating ovarian failure) are
' igible.
It appears to us that most programs either use
Iniphene citrate or human menopausal gonado-
Din (hMG) regimens to control follicular growth.
> ' program uses a combined clomiphene-hMG-hCG
e men which appears to give us relatively controlled,
Hietable growth of follicles. Nonetheless, a signifi-
c t number of induction cycles were terminated prior
>urgeiy because of inappropriate follicular response.
II complications were encountered with this ap-
lach.
Whereas many programs use a rapid LH assay to
< ne the LH surge, we rely on other criteria to evalu-
patients just prior to laparoscopy. Our criteria for
deeding with laparoscopy include: 1) a normal
I
I
t 81— NUMBER 10— OCTOBER 1984
estradiol profile; 2) sonographically defined pro-
gressive follicular growth; and 3) at least two sono-
graphically defined follicular cysts for harvesting. The
rationale of this approach is to obtain germ cells from
well-stimulated follicles in adequate number to im-
prove the overall chance of success.
• Many programs use medication to support the
luteal phase and, in general, progesterone supplemen-
tation appears popular. We are using a supplemental
regimen of hCG, on the basis that hCG will stimulate
the ovarian corpus luteum and then raise both en-
dogenous estrogen and progesterone, whereas ex-
ogenous progesterone supplementation may distort
the estrogen/progesterone ratio.
Our results fall well within those seen in the reported
IVF experience: the efficacy of IVF in summary of 2,037
laparoscopies done worldwide at 12 centers indicates
a transfer rate of 55 percent, and a pregnancy rate of
8 percent; the pregnancy rate was 16.5 trans-
fers/pregnancy.6 Our results are very similar to this
overall experience. Although the future of IVF appears
promising, there are a number of issues which require
careful attention. Foremost, the efficiency (preg-
nancies/laparoscopy) of IVF procedures needs to be
improved. As a medical procedure, IVF still is in the
early developmental stage and it is reasonable to expect
significant improvement with cumulative experience.
As efficiency increases, IVF may compete more effec-
tively with tubal surgery as a primary approach to
overcome tubal infertility. Applications other than
tubal problems need to be defined further. As most
centers, we have opened access to our program now
to those patients who have unexplained infertility, en-
dometriosis with failed previous therapy, and patients
whose husbands have untreatable oligospermia. At the
same time, however, it should be recognized that pa-
tients in these latter categories may have
pathophysiologies less amenable to IVF therapy than
those with tubal occlusions. We also increased the age
limit to allow patients up to 39 years to enter the
program.
A major problem for many patients is the current
classification of IVF procedures as “experimental” by
insurance carriers. The expense of the procedure
(about $5,000 per attempt) is composed of labor in-
tensive elements many of which are, by themselves,
accepted medical procedure. The current situation
makes it difficult for a sizable number of infertile cou-
ples for whom IVF offers perhaps the only possibility
for achieving pregnancy to take advantage of this
procedure’s potential.
ADDENDUM
Since the completion of the article both patients who
were pregnant have delivered. Patient 1 was delivered
at term by cesarean section on July 18, 1984, of a
healthy, male infant weighing 10 pounds, 1 ounce. The
indication was cephalopelvic disproportion with a
large infant who never entered the pelvis. The prior
pregnancy course had been uneventful.
Patient 2 delivered at 37'/2 weeks a healthy 6 pound,
5 ounce male infant on July 23, 1984. This delivery also
was by cesarean section with an indication of placenta
previa During this pregnancy, several episodes of pain-
853
less vaginal bleeding had occurred since July 3, and
required hospitalization on two occasions. Sonogram
studies indicated placenta previa as cause. Delivery
occurred electively after maturity studies had been per-
formed, and the operation confirmed the presence of
a placenta previa
Both mothers and infants are doing well.
REFERENCES
1. Step toe PC, Edwards RG: Birth after the reimplantation
of a human embiyo. Lancet 2:366, 1978.
2. Jones HW Jr, Jones GS, Andrews HC, Acosta A, Bundren
C, Garcia J, Sandow B, Veeck L, Wilkes C, Witmyer J, Worth :
JE, Wright G: The program for in vitro fertilization at North
Fert Steril 38:14-21, 1982.
3. Garcia J, Acosta A, Andrews MC, Jones GS, Jones ]|l
Jr, Mantzaviros T, Mayer F, McDowell J, Sandow B, Veecl.
Whibly T, Wilkes C, Wright G Jr: In vitro fertilization in A
folk, Virginia 1980-1983. J In Vitro Fert Embryo Tra,
1:24-28, 1984.
4. Acosta A Proceedings of the in vitro fertilization wc;
shop, Norfolk, VA, Sept 1982. Infertility, 6:1-4, 1983.
5. Jones HW Jr, Acosta A Garcia J, Sandow B, Veeck L: -
the transfer of conceptuses from oocyte fertilized in vitro. I-
Steril 39:241-243, 1983.
6. Grobstein C, Flower M, Mendeloff J: Scieit
222:127-133, 1983.
I
854
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
New low price...major savings
The dramatic reduction in the price ot Motrin Tablets means substantial savings
trom now on tor your patients and tor patients all across the country tor whom Motrin
Tablets are prescribed.
Motrin is priced lower than Clinoril, Feldene, or Naprosyn.
The price of Motrin Tablets to pharmacies has been reduced as much as 35%.
Patients taking the average dosage should now pay less for therapy with Motrin Tablets
than for almost any other nonsteroidal anti-inflammatory drug you
prescribe... less, for example, than for Clinoril, Feldene, or Naprosyn. And, of course,
all strengths of Motrin Tablets continue to be available by prescription only.
Please see the following page for a brief summary of prescribing information.
• /*■
iDunroren
TABLETS
mo
Good medicine...good value
© 1984 The Upjohn Company
The Upjohn Company
Upjohn
Kalamazoo, Michigan 49001
i
<. 81— NUMBER 10— OCTOBER 1984
855
Motrin® Tablets (ibuprofen)
Contraindications: Anaphylactoid reactions have occurred in individuals hypersensitive to
Motrin Tablets or with the syndrome of nasal polyps, angioedema and bronchospastic reactivity
to aspirin, iodides, or other nonsteroidal anti-inflammatory agents.
Warnings: Peptic ulceration and Gl bleeding, sometimes severe, have been reported. Ulceration,
perforation and bleeding may end fatally. An association has not been established. Use Motrin
Tablets under close supervision in patients with a history of upper gastrointestinal tract disease,
after consulting ADVERSE REACTIONS. In patients with active peptic ulcer and active
rheumatoid arthritis, try nonulcerogenic drugs, such as gold. If Motrin Tablets are used, observe
the patient closely for signs of ulcer perforation or Gl bleeding.
Chronic studies in rats and monkeys have shown mild renal toxicity with papillary edema and
necrosis. Renal papillary necrosis has rarely been shown in humans treated with Motrin Tablets.
Precautions: Blurred and/or diminished vision, scotomata, and/or changes in color vision have
been reported. If these develop, discontinue Motrin Tablets and the patient should have an
ophthalmologic examination, including central visual fields and color vision testing.
Fluid retention and edema have been associated with Motrin Tablets; use with caution in patients
with a history of cardiac decompensation or hypertension. In patients with renal impairment,
reduced dosage may be necessary. Prospective studies of Motrin Tablets safety in patients with
chronic renal failure have not been done.
Motrin Tablets can inhibit platelet aggregation and prolong bleeding time. Use with caution in
persons with intrinsic coagulation defects and on anticoagulant therapy.
Patients should report signs or symptoms of gastrointestinal ulceration or bleeding, skin rash,
weight gain, or edema.
Patients on prolonged corticosteroid therapy should have therapy tapered slowly when Motrin
Tablets are added.
The antipyretic, anti-inflammatory activity of Motrin Tablets may mask inflammation and fever.
As with other nonsteroidal anti-inflammatory drugs, borderline elevations of liver tests may
occur in up to 15% of patients. These abnormalities may progress, may remain essentially
unchanged, or may be transient with continued therapy. Meaningful elevations of SGPT or SGOT
(AST) occurred in controlled clinical trials in less than 1% of patients. Severe hepatic reactions,
including jaundice and cases of fatal hepatitis, have been reported with ibuprofen as with other
nonsteroidal anti-inflammatory drugs. If liver disease develops or if systemic manifestations
occur (e.g. eosinophilia, rash, etc.), Motrin should be discontinued.
Drug interactions. Aspirin: used concomitantly may decrease Motrin blood levels.
Coumarin: bleeding has been reported in patients taking Motrin and coumarin.
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy or by nursing
mothers.
Adverse Reactions: The most frequent type of adverse reaction occurring with Motrin is
gastrointestinal of which one or more occurred in 4% to 16% of the patients.
Incidence Greater than 1% (but less than 3%)- Probable Causal Relationship
Gastrointestinal: Nausea,* epigastric pain* heartburn,* diarrhea, abdominal distress, nausea
and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of Gl tract (bloating
and flatulence); Central Nervous System: Dizziness,* headache, nervousness; Dermatologic:
Rash* (including maculopapular type), pruritus, Special Senses: Tinnitus; Metabolic/Endocrine:
Decreased appetite; Cardiovascular: Edema, fluid retention (generally responds promptly to
drug discontinuation; see PRECAUTIONS).
Incidence less than 1%-Probable Causal Relationship**
Gastrointestinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastrointestinal
hemorrhage, melena, gastritis, hepatitis, laundice, abnormal liver function tests; Central
Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, aseptic
meningitis with fever and coma; Dermatologic: Vesiculobullous eruptions, urticaria, erythema
multiforme, Stevens-Johnson syndrome, alopecia; Special Senses: Hearing loss, amblyopia
(blurred and/or diminished vision, scotomata, and/or changes in color vision) (see PRECAU-
TIONS); Hematologic: Neutropenia, agranulocytosis, aplastic anemia, hemolytic anemia (some-
times Coombs positive), thrombocytopenia with or without purpura, eosinophilia, decreases in
hemoglobin and hematocrit; Cardiovascular: Congestive heart failure in patients with marginal
cardiac function, elevated blood pressure, palpitations; Allergic: Syndrome of abdominal pain,
fever, chills, nausea and vomiting; anaphylaxis; bronchospasm (see CONTRAINDICATIONS),
Renal: Acute renal failure in patients with pre-existing significantly impaired renal function,
decreased creatinine clearance, polyuria, azotemia, cystitis, hematuria; Miscellaneous: Dry eyes
and mouth, gingival ulcer, rhinitis.
Incidence less than 1%-Causai Relationship Unknown**
Gastrointestinal: Pancreatitis; Central Nervous System: Paresthesias, hallucinations, dream
abnormalities, pseudotumor cerebri; Dermatologic: Toxic epidermal necrolysis, photoallergic
skin reactions; Special Senses: Conjunctivitis, diplopia, optic neuritis; Hematologic: Bleeding
episodes (eg , epistaxis, menorrhagia); Metabolic/Endocrine: Gynecomastia, hypoglycemic
reaction; Cardiovascular: Arrhythmias (sinus tachycardia, sinus bradycardia); Allergic: Serum
sickness, lupus erythematosus syndrome, Henoch-SchOnlein vasculitis; Renal: Renal papillary
necrosis.
‘Reactions occurring in 3% to 9% of patients treated with Motrin. (Those reactions occurring in
less than 3% of the patients are unmarked.)
♦♦Reactions are classified under ' 'Probable Causal Relationship ( PCR )" if there has been one
positive rechallenge or if three or more cases occur which might be causally related. Reactions
are classified under Causal Relationship Unknown" if seven or more events have been reported
but the criteria for PCR have not been met.
Overdosage: In cases of acute overdosage, the stomach should be emptied. The drug is acidic
and excreted in the urine so alkaline diuresis may be beneficial.
Dosage and Administration: Rheumatoid arthritis and osteoarthritis. Suggested dosage is 300,
400, or 600 mg t.i.d. or q.i.d. Do not exceed 2400 mg per day. Mild to moderate pain: 400 mg
every 4 to 6 hours as necessary.
Caution: Federal law prohibits dispensing without prescription. med b-7-s
Motrin is a registered trademark of The Upphn Manufacturing Company.
Upjohn
The Upjohn Company
Kalamazoo, Michigan 49001
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS T.
856
Myth or Fact:
Dan Women Self-Diagnose Pregnancy?
Gloria a. Bachmann, m.d., new Brunswick*
The unproved belief that most women can self-diagnose
pregnancy before medical confirmation is accepted widely. To
test the accuracy of self -diagnosis, 283 women who requested a
pregnancy test because of late menses were asked to complete
a structured , self-administered questionnaire.
The diagnosis of pregnancy is
based on symptoms and signs,
especially missed menses,
licited by history taking, physical examination, and
iboratoiy procedures. Most often the diagnosis rests
1th detection of human chorionic gonadotropin
iCG) in urine or serum.1 Although some current preg-
aney tests can detect HCG nine days after ovulation,
i general most detect HCG after the first missed
lenses. However, false negative and false positive re-
ults can occur because of substances interfering with
le HCG measurement or by HCG or HCG-like
scretion in the absence of pregnancy.2 Moreover, HCG
etection in the urine is a probable sign of pregnancy
ither than an absolute sign. Identification of fetal
eart activity, perception of fetal movement by the
Kaminer, and the recognition of the fetus radio-
igically or sonographically are considered absolute
;gns of pregnancy.
Some physicians believe that the diagnosis of preg-
ancy can be supported before absolute signs are rec-
gnizable by asking the woman if she is pregnant.3
elf-predietion of pregnancy is of special interest in the
rea of in vitro fertilization.
Can women accurately predict those cycles in which
ie implanted fertilized ovum has resulted in a preg-
ancy? This research studied the accuracy of a
Oman's self-prediction of pregnancy before preg-
ancy test results and physical examination were
known to her. It also evaluated specific factors affect-
ing her diagnosis.
MATERIALS AND METHODS
Two hundred eighty-three women, aged 16 through
28 years (mean, 22.8 years), who requested a preg-
nancy test because of a late menses, were studied at
three health centers in New Brunswick. Six women (2
percent) of the sample wanted to be pregnant. Sixty-
four (23 percent) women had previous pregnancy ex-
perience. Ninety-eight percent of the sample had their
last menses 60 days or less before requesting a preg-
nancy test. Each woman was asked to fill out a com-
prehensive, structured contraception and sexual his-
tory questionnaire which included questions on
whether she believed she was pregnant, and if subjec-
tive symptoms of pregnancy were present. All question-
naires were filled out before the results of the preg-
nancy test (NeoCept®) were available and before a
physical examination was done.
NeoCept® is a urine test for pregnancy based on the
hemagglutination inhibition reaction between HCG-
sensitized blood cells and antisera to HCG. It is positive
*Dr. Bachmann is affiliated with the Department of Ob-
stetrics and Gynecology, UMDNJ-Rutgers Medical School.
Correspondence may be addressed to Dr. Bachmann, UMDNJ-
Rutgers Medical School, Department of Obstetrics and
Gynecology, Academic Health Science Center, CN 19, New
Brunswick, NJ 08903.
9L. 81— NUMBER 10— OCTOBER 1984
857
at an average of 16 days after ovulation, at which time
the concentration of HCG in the urine is about 200
mIU/ml.4 This corresponds to about the time of the
first missed period.
RESULTS
Of the 283 pregnancy tests, 118 (42 percent) were
positive and 165 (58 percent) were negative. Of 118
women with positive pregnancy tests, 92 percent were
correct in stating they were pregnant; women with
previous pregnancy experience were 94 percent ac-
curate. Of 105 women with negative pregnancy tests,
57 percent incorrectly stated they were pregnant; 64
percent with previous pregnancy experience incorrect-
ly thought they were pregnant.
Accuracy of Prediction. Of the 283 women request-
ing pregnancy tests, 204 thought they were pregnant,
however, only 109 (53 percent) did have a positive
pregnancy test. Of the 79 subjects who did not think
they were pregnant, 70 (89 percent) were correct and
had negative pregnancy tests while 9(11 percent) were
inaccurate and indeed were pregnant (Figure). Of the
study population, 64 women who had previous preg-
nancy experience were not more accurate in their pre-
diction of pregnancy than the rest of the group.
Subjective Symptoms and Signs of Pregnancy. Of
the 118 subjects with positive pregnancy tests, 59 (50
percent) felt pregnant as compared to 34 (21 percent)
of the 165 women with negative pregnancy tests.
Accuracy of Pregnancy Prediction of Subjective
Symptoms. Eighty-nine (44 percent) of the 204 women
who thought they were pregnant had subjective symp-
toms of pregnancy. Of these 89 women, 57 subsequent-
ly had a positive HCG. Therefore, of all women who
thought they were pregnant, only 57 (29 percent) had
symptoms of pregnancy and indeed were pregnant; 32
women ( 1 5 percent) had symptoms but were not preg-
nant.
Of the 79 women who did not think they were preg-
nant, only 5 percent had symptoms of pregnancy. Of
this group, only 2 (3 percent) with a subsequently
negative test reported subjective symptoms.
Unprotected Intercourse and Contraceptive Use.
Women who felt they were pregnant reported the high-
er percentage of unprotected intercourse (59 percent
as compared to 36 percent). As expected, women who
thought they were pregnant and subsequently had a
positive pregnancy test had the higher rate of un-
protected intercourse (71 percent), and the higher per-
centage of failure to use contraceptive agents (16 per-
cent compared to 10 percent).
DISCUSSION OF RESULTS
Women who requested a pregnancy test to rule out
an unwanted pregnancy did not have a high degree of
accuracy in predicting pregnancy. Only 53 percent
were correct in accurately self-diagnosing pregnancy.
However, of those women not believing they were preg-
nant, 89 percent were accurate. Symptoms of preg-
nancy were reported more often by women with
positive pregnancy tests who thought they were preg-
nant, but subjective symptoms were not more accurate
than the woman’s self-prediction of pregnancy. The
Accuracy of Self-Diagnosis of Pregnancy
niques as compared to those who did not think th
were pregnant. In fact, more women requested a pr<
nancy test because of unprotected intercourse th
because of pregnancy symptoms. Despite recent £
vances in fertility control techniques, many worm
especially in this younger population avoid or are i
consistent with contraception.
SUMMARY
It appears that self-diagnosis is not accurate in pi
dieting pregnancy and physicians should not rely <
history alone. Many women assume that they are pre:
nant after a missed menstrual period until pregnan;
testing and pelvic examination give them a conclusij
answer. However, if a woman states she is not prej
nant, she most probably is correct. Data from a popi
lation of women desirous of pregnancy and from
population of women undergoing in vitro fertilizatii
are needed for comparison.
REFERENCES
1. Williams: Obstetrics, 12th Edition. 1980, p. 261.
2. Horwitz CA Pregnancy tests 1980: Advantages and lir
tations. Lab Med 11:620, 1980.
3. Derman R, Corson S, Horwitz CA Lau HL, Soderstrci
R Early diagnosis of pregnancy: A symposium. J Repro M
26:4, 1981.
4. Wang CF, Gemzell C: Neocept®: A simple, sensitive uri
test of early pregnancy in women undergoing ovulation
duction. J Repro Med 4:193-195, 1982.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
858
(BR5M2) THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, CA 90057
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Start with 80 mg once daily. . - Dosage may be increased to
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Please see next page for further details and brief summary of
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> hi
80 120 160
mg mg mg
The appearance ol INDERAL LA capsules
is u registered trademark ol Aycrsl Laboratories
Ayerst
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HCI) CAPSULES
1
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg. 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonseleclive beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) tor the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear !o be minor and .g^piewhat variable INDERAL has
been shown to cause a small increase in serum potassi J||f:oncentration when usecjpf| the
treatment of hypertensive patients * gg
In angina pectoris, propranolol generally reduces the oxygen requirement Of lhe?hea#%t
any given level of effort by blocking the catecholamme*K^^b inc^^few,the hqg|l/rate.
systolic blood pressure, and the velocity and extent offlBMSr dial
may increase oxygen requirements by increasing left i ventricular tajigf* lenjffl^jjljflPstolic
pressure and systolic election period The net physiologic effect ol beta-adru ;urgic blockade
is usually advantageous and is manifested during mm'i n o by delayed ••wise! o‘ pain and
increased work capacity
In dosages greater than required for beta blockade. INDERAL also exerts a quinidine |pt'
or anesthetic -like membrane action which affects the Cardiac action potential.: THe sigftifF
cance of the membrane action in the treatment of arpwniffltfe i^^cen» i*:'. * f
The mechanism ol the antimigraine effect of piopranoW has not beefi.estaSlished Beid
adrenergic receptors have been demonstrated in the plat vfessefe of the brain
Bela receptor blockade can be useful in condSns m which, because of pathoiogBbr
functional changes, sympathetic activity is detrim^^J§?fh(f:j^ai#it.'But there are also
situations in which sympathetic stimulation is vital RfYAxampleHri paffents WTrrT severely
damaged hearts, adequate ventricular function is maintained by virtue ol sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension, it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY. The necessity or desirability of withdrawal of beta-blockincjjb
prior to maior surgery is controversial. It should be noted, however, that the impaired:!
the heart to respond to reflex adrenergic stimuli may augment the risks of general ar;|
and surgical procedures
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor®
receptor agonists and its effects can be reversed by administration of such age;‘|
dobutamine or isoproterenol However, such patients may be subject to protracts ■
hypotension Difficulty in starting and maintaining the heartbeat has also been repe l
bst3 blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may preven m
pearance of certain premonitory signs and symptoms (pulse rate and pressure cht.l
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may I
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperth
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of s j
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid fund:
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases h;
reported in which, after propranolol, the tachycardia was replaced by a severe braj
requiring a demand pacemaker In one case this resulted after an initial dose
propranolol
PRECAUTIONS. General. Propranolol should be used with caution in patients with j
hepatic or renal function. INDERAL is not indicated for the treatment of hypd
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure
should be told that INDERAL may interfere with the glaucoma screening test Withdr,!
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests Elevated blood urea levels in patients with severe heart
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such
pine should be closely observed if INDERAL is administered. The added catecf
blocking action may produce an excessive reduction of resting sympathetic nervou
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, oro:
hypotension.
Carcinogenesis. Mutagenesis, Impairment ol Fertility: Long-term studies in anin
been conducted to evaluate toxic effects and carcinogenic potential In 18-month ;
Jaotbrats and rrji|Ai,employtngdoses..i4>tQj50mg/kg/day. there was no evidence of s
drug-tndiiced, toxicity There y^e|ho drug-jelated tumorigenic effects al any of tht
flevel^fc^pSductive studies m animals did not show any impairment of fertility ;
[ attributable 'to thjHBK
PLetijn£ncy tSuShcv GaJgbry C -INDERAL has been shown to be embry
^ni^Slrsmies a^Jpses about 10 times greater than the maximum recommended hunt
Theii’are no adequate ah'd welt-controlled studies in pregnant women INDER/
be used during pregnancy only if the potential benefit justifies the potential risk to j
Nursing Mottfms INDERAL is excreted in human milk Caution should be exerci;
■ ITJ DERAILS administered to a nursing woman
L PeoSmc Use: Safely and effectiveaifts in children have not been established
ADVERSE REACTIONS. Most adjalpse effects have been mild and transient ;l
rpreiy required the withdrawal pf therapy
jo. Gjj%’yiovagpLtl$r: jbradj&afdia) congestive heart failure, intensification of AV blot
’ tensiotK^esthe Jaoi nands thrombocytopenic purpura, arterial insufficiency, usu;
‘TteynauoType k hP - *
Central Nervous System: hghtbuadedness. mental depression manifested by ij
lassitude, weakness, fatiguer^rersibie mental depression progressing to cataton
disturbances, hallucinations; an acute reversible syndrome characterized by disorier
time and place, short-term memory loss, emotional lability, slightly clouded sensor
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping,
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined wi :
and sore throat, laryngospasm and respiratory distress
Respiratory: bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thromboc|
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus Tt
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, mr
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous
involving the skin, serous membranes and coniunctivae reported for a beta blocker (|
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochli;
sustained-release capsule for administration once daily. If patients are switched from I
tablets to INDERAL LA capsules, care should be taken to assure that the desired thr,
effect is maintained INDERAL LA should not be considered a simple mg for mg sub
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitr;
be necessary especially to maintain effectiveness at the end of the 24-hour dosinc
HYPERTENSION — Dosage must be individualized. The usual initial dosage i
INDERAL LA once daily, whether used alone or added to a diuretic. The dosagel
increased to 120 mg once daily or higher until adequate blood-pressure control is e
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosa
mg may be required. The time needed for full hypertensive response to a given c
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDi
once daily, dosage should be gradually increased at three to seven day intervals until'
response is obtained Although individual patients may respond at any dosage !i
average optimum dosage appears to be 160 mg once daily In angina pectoris, the vi
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a fe *
(see WARNINGS). f
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDIj
once daily. The usual effective dose range is 160-240 mg once daily The dosage
increased gradually to achieve optimum migraine prophylaxis If a satisfactory respoi
obtained within four to six weeks after reaching the maximum dose, INDERAL Lf
should be discontinued It may be advisable to withdraw the drug gradually over a
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age grout)
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Lab;
AYERST LABORATORIES
New York, N.Y. 10017
Ayerst
862
VOL. 81— NUMBER 10— OCTOBER IT*
USKS Associated With
^ST-TRAUMATIC FLASHBACKS*
Allan Burstein, m.d., freehold*
Post-traumatic flashbacks occur in 8 to 13 percent of persons
following a war experience , catastrophe , motor vehicle or
industrial accident , or assault. Sixty patients were evaluated and
13 were found to have post-traumatic flashbacks. Physicians
should anticipate problems and look for and treat flashbacks.
Post- traumatic flashbacks are
clearly perceived revisualiza-
tions of the trauma scene or a
luma-related scene occurring with realistic intensi-
The traumatic experience may be a war experience,
catastrophe, or much more prevalent traumas such
; motor vehicle accidents, industrial accidents, or as-
ults. An incidence for flashbacks of 8 to 13 percent
is been noted in bereaved widows,1, combat veterans,2
id a mixed trauma group.3
The dangers associated with hallucinations, as
cur in schizophrenia or delirium, are well-ree-
i*;nized.4 In response to an imagined threat, the indi-
idual may exhibit a flight reaction and, for example,
ap from an open window. It is believed that such
jght reactions are possible with post-traumatic
ishbacks, but very few references to this problem
lapear in the literature. Furthermore, such possibl-
es are not necessarily recognized by the physician
eating the victims of motor vehicle accidents, as-
lults, or other commonly seen traumas.
ETHOD AND RESULTS
The following study was undertaken to ascertain the
evalence of dangerous flashbacks commonly en-
auntered among medical-surgical patients referred
|r psychiatric consultation.
Sixty patients who met the DSM III criteria for post-
aumatic stress disorder (Table) were evaluated as
they were referred from medical specialists for consul-
tation in the hospital or office. The evaluation con-
sisted of an interview and confirmation of symptoms
from a family member or from a treating professional.
Twenty (33 percent) of this group reported
flashbacks (10 males and 10 females; mean age 32.3).
Care was taken to distinguish between revisualiza-
tions and other visual imagery, i.e. illusions. Confirma-
tion was obtained in 13 eases. The traumatic stresses
involved were: motor vehicle accidents (n = 1 1 ); assaults
(n = 4); work-related accidents (n = 3); and other (n = 2).
The mean time from the trauma to the evaluation was
32.7 weeks. Of these 20 patients, none had a prior
history of psychiatric problems or manifestations of
psychotic symptoms, or alcohol or drug abuse.
In all cases, the revisualizations, which consisted of
a scene from the trauma lasting for a minute or less,
were precipitated by an event reminiscent of the
trauma (a thought, a pain, or a similar situation). The
flashbacks occurred either frequently (several
times/week, n = 16) or rarely (2 or fewer episodes, n = 4).
In nine of these cases (45 percent) the flashbacks
precipitated either a dangerous or a potentially
dangerous situation, according to the judgment of the
patients, witnesses, and this investigator. The trau-
*Dr. Burstein is in private practice. Correspondence may be
addressed to Dr. Burstein, Wemrock Professional Mall, 505
Stillwells Comer Road, Freehold, NJ 07728.
0L. 81— NUMBER 10— OCTOBER 1984
863
matic events in these eases were either a motor vehicle
accident (n = 8) or an industrial accident (n=l). In this
group, confirmation was obtained in seven cases.
CASE REPORT 1
A 35-year-old petrochemical worker was involved in
a plant explosion. Severe bums resulted in a lengthy
hospitalization. During that time he began to ex-
perience frightening dream disturbances in which
scenes of the accident were repeated. He became de-
pressed and, once home, quarreled often with his wife.
There was no sexual interest nor interest in any of his
prior activities. At times he would start to cry for no
apparent reason. Seven months after the accident he
returned to work, but several weeks later there was
another explosion. Standard procedure at the plant
would have been an immediate response on his part
to help his coworkers and stop the fire. However, he
froze at the sight of the flames and revisualized his
prior accident. Subsequently, he felt guilty and quite
vulnerable. He requested and was granted a change in
work status.
CASE REPORT 2
A 22-year-old woman was involved in a motor vehicle
accident which resulted in facial lacerations and or-
thopedic injuries. Following the accident, she began to
have dream disturbances involving a repetition of the
accident. The dreams were so vivid that sleep which
already was disturbed became impossible. She was de-
pressed, withdrew from social relationships, and dis-
continued her modeling career. When she resumed
driving she found herself experiencing frequent (sev-
eral per week) flashbacks of the accident. At times, she
would “freeze” behind the wheel, scream, or “slam on
the brakes." She attempted to cope with the flashbacks
by either not driving or driving as slowly as possible.
DISCUSSION
This study suggests that flashbacks occurring dur-
ing tasks that involve concentration and quick judg-
ment pose a risk to the patient and others. Moreover,
they are not rare in general medical practice. This
evaluation only dealt with patients who were referred
for psychiatric consultation. Many medical and
surgical practitioners, however, treat their patients’
psychiatric disorders without psychiatric consul-
tation.5 Hence, this study reflects only a glimpse of the
total picture.
Two reasons for the poor recognition of flashbacks
in general practice are suggested. Firstly, a clear, con-
sistent post-traumatic symptom picture has been
recognized only within the past few years. Post-trau-
matic stress disorder formerly was called gross stress
reaction, traumatic neurosis, shell shock, or combat
fatigue by different investigators. The presentation
may be complicated and confusing to the primary
physician.
Secondly, as Horowitz has suggested, patients often
will not report flashbacks unless specifically asked6
seeing them as symptoms of “madness” or loss of
control.
At this point, treatment considerations are tentative.
One pilot study indicates that those individuals ex-
periencing post-traumatic dream disturbances are at
TABLE
Diagnostic Criteria Jor Post-traumatic Stress Disorder*]
A Existence of a recognizable stressor that would evokt
significant symptoms of distress in almost everyone
B. Re-experiencing of the trauma as evidenced by a
least one of the following:
(1) Recurrent and intrusive recollections of th<
event
(2) Recurrent dreams of the event
(3) Sudden acting or feeling as if the traumatii
event were reoccurring, because of an associa
tion with an environmental or ideational stimu
lus
C. Numbing of responsiveness to or reduced involve
ment with the external world, beginning some timi
after the trauma as shown by at least one of th
following:
( 1 ) Markedly diminished interest in one or more sig
nificant activities
(2) Feeling of detachment or estrangement fron
others
(3) Constricted affect
D. At least two of the following symptoms that were nc
present before the trauma
(1) Hyperalertness or exaggerated startle response
(2) Sleep disturbance
(3) Guilt about surviving when others have not, o
about behavior required for survival
(4) Memory impairment or trouble concentrating
(5) Avoidance of activities that arouse recollection c
the traumatic event
(6) Intensification of symptoms by exposure t
events that symbolize or resemble the traumatf
event
*From the Diagnostic and Statistical Manual of Mentc
Disorders. 3rd Edition. American Psychiatric Associatior
risk to experience flashbacks.7 Case reports suggi
that phenelzine8 and imipramine9 may stop flashbac
as well as calm the patient and control the sleep aj
dream disturbances. However, more formal study
the problem of post-traumatic flashbacks must
done.
REFERENCES
1 . Parkes CM: The first year of bereavement: A longitudii
study of reaction of London widows to the death of th
husbands. Psychiatry 33:444-467, 1970.
2. Panzarella RF, Mantell DM, Bridenbargh RH: Psychiat
syndromes, self concepts, and Vietnam veterans, in Figley (
(ed). Stress Disorders Among Vietnam Veterans. New Yo
NY, Bruner Mazel, 1978, p. 161.
3. Horowitz MJ, Wilner H, Kaltreider N, et al.: Signs a
symptoms of post-traumatic stress disorder. Arch Gen Pi
chiatry 37: 85-92, 1980.
4. Linn L: Clinical manifestations of psychiatric disorde
in Kaplan HI, Freedman AM, Sadock BJ (eds), Co
prehensive Textbook of Psychiatry/III. Baltimore, MD, V
liams and Wilkins, 1980, p. 1018.
5. Fauman MA Psychiatric components of medical a
surgical practice, II: Referral and treatment of psychiat
disorders. Am J Psychiatry 140: 760-763, 1983.
6. Horowitz MJ: Stress Response Syndromes. New Yo
NY, Jason Aronson Inc., 1976, p. 37.
7. Burstein A Dream disturbances and flashbacks. J C
Psychiatry (in press).
8. Hogben GL, Cornfield RB: The treatment of trauma
war neurosis with phenelzine. Arch Gen Psychiol
38:440-445, 1981.
9. Burstein A Imipramine treatment of flashbacks. Arf
Psychiatry 140:509, 1983.
864
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
VOTE.
EXERCISE
YOUR
RIGHT.
NOVEMBER 6, 1984
A Public Service of JEMPAC
Copies of JEMPAC and AMPAC reports are filed with the Federal Election Commission and are available for purchase from
The Federal Election Commission, Washington, D.C.
L. 81— NUMBER 10— OCTOBER 1984
865
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSY
!
HlDTRIMESTER AMNIOCENTESIS
fOR Prenatal Diagnosis
Abraham Ghiatas, m.d., long branch*
i
At Monmouth Medical Center , 152 women underwent
amniocentesis because of advanced maternal age, suspected
neural tube defect, or adverse family history for chromosomal or
biochemical disorders. Amniocentesis in the midtrimester of
pregnancy is a safe and accurate method of prenatal diagnosis.
The improvement of cytogenetic
and tissue culture techniques
as well as the widespread ac-
“ptanee of amniocentesis as a diagnostic aid, have
lowed the detection of many inborn errors of
iietabolism and chromosome abnormalities, such as
isomy 21 and Tay-Sachs disease.
In 1955, investigators were using the presence of x-
uromatin in the nuclei of amniotic fluid cells for
renatal sex determination.4 In 1965, adrenogenital
/ndrome was diagnosed in a fetus by measuring the
vels of 17 ketosteroids and pregnanetnol in amniotic
uid obtained in the 39th week of gestation.4 In 1966,
le technique of amniotic fluid cell culture was in-
oduced.4
TOICATIONS
Amniocentesis is indicated when the risk of an ab-
ormal child is greater than the risk of fetal ab-
ormalities in the general population: advanced ma-
mmal age (over 35 years), previous birth of a child with
liown’s syndrome or any other trisomy, or previous
irth of a child with a neural tube defect such as
leningomyelocele.236 Also, it is indicated when the
imily history suggests that one parent has or may be
carrier of a disorder that has a chromosomal or
ioehemical etiology.3-6
The results from the work performed at Monmouth
ledical Center are shown in Tables 1, 2, and 3.
TECHNIQUE
The procedure is simple. After the abdomen is
prepared aseptieally, 1 percent lidoeaine is used as a
local anesthetic. A 22-gauge spinal needle with stylet
is used to obtain approximately 30 ml of amniotic
fluid. To avoid contaminating the sample with ma-
ternal tissue, the stylet must be in place when the
needle is advanced. One syringe is used to draw the
initial 0.5 ml of fluid to be sure it is clear of blood and
then a second syringe is used to obtain the specimen.5
Ultrasonography is used prior to amniocentesis to
localize placenta fetus, and fetal age. Also, ultra-
sonography provides information of the optimal site
and depth for insertion of the needle to obtain a sam-
ple of amniotic fluid. This is marked on the abdominal
wall and amniocentesis is carried out immediately
thereafter to minimize changes related to movement
of the fetus.
The preferred gestational age for amniocentesis is
between 15 to 20 weeks which allows sufficient time
to repeat amniocentesis if cell culture fails and also
allows a diagnosis before quickening.
After amniocentesis is completed, the fetal heart ac-
tivity is observed by using ultrasonography.
*Dr. Ghiatas is a resident in diagnostic radiology at Mon-
mouth Medical Center. Long Branch. Correspondence may be
addressed to Dr. Ghiatas, Monmouth Medical Center, Third
and Pavilion Avenues, Long Branch, NJ 07740.
OL. 81— NUMBER 10— OCTOBER 1984
867
TABLE 1
Indications for Amniocentesis
Indications
No.
%
Advanced maternal age
(included also border-
line advanced maternal
age)
141
92.7
Neural tube defect
8
5.3
Other
3
2.0
Gestational Age
TABLE 2
Gestationcd Age
No.
%
Under 15 weeks
2
1.3
15 to 20 weeks
149
98.1
Over 20 weeks
1
0.6
RESULTS AND DISCUSSION
Amniocentesis, a joint procedure at Monmouth
Medical Center performed by the Department of Ob-
stetrics and Gynecology and the Department of Radi-
ology, was performed on 152 women over a period of
two years (1981 to 1983). Of this group, 120 (78.9
percent) were between 35 to 39 years of age, 12 (7.9
percent) were over 40 years of age, and 20 (13.2 per-
cent) were below the age of 35 (in this group also was
included the borderline advanced maternal age,
women age 34 to 35). The indications for am-
niocentesis are summarized in Table 1.
In the group, "other,” were two women aged 33 and
28 who underwent amniocentesis due to maternal
anxiety and one woman who had multiple radiologic
examinations during childhood (age 24).
The reasons given for neural tube defect were:
previous deliver/ of aneneephalie child; previous de-
livery of hydrocephalic and spina bifida child; previous
delivery of Down’s syndrome child; and family history
of Down's syndrome.
Analysis of Table 1 indicates that 98 percent of the
performed amniocenteses were indicated and only 2
percent of them were not justified.
The gestational age at the time of amniocentesis is
shown in Table 2. Table 2 indicates 98. 1 percent of the
amniocenteses were performed at the indicated gesta-
tional age (15 to 20 weeks) and only 1.9 percent were
performed either earlier or later than the indicated
gestational age.
The number of attempts to obtain amniotic fluid as
well as the gestational week when the attempt was
done are shown in Table 3.
Analysis of Table 3 shows that in 89.4 percent of the
amniocenteses, amniotic fluid was obtained at the fir
attempt and 5.3 percent at the second attempt. T1
reason for repeated amniocentesis was failure to oi
tain fluid on the first or second tap. The reason ford
tap was the patient's refusal to allow second tap aft
the failure of the first.
COMPLICATIONS
The complications of amniocentesis15,6 can )h
divided into two groups. The first is fetal compile!
tions: direct fetal trauma; cord hematoma; hemorrha
and preterm labor; and premature rupture of the met
branes.
The second group is maternal complications: ai
nionitis; fetomatemal transfusion; amniotic fluid ei
holism; and Rh — isoimmunization.
Only one patient had a complication related to a i,
niocentesis. After the amniocentesis, she abort'
spontaneously. Communication with the majority
the patients, the attending physicians, and the gene!
counseling office at Monmouth Medical Center did n
reveal any other complications.
All of the obtained amniotic fluids were clear exce
11 (7.1 percent) amniocenteses where the amnioi
fluid was slightly bloody but did not interfere with t
cell culture. Only one cell culture indicated trisomy :
and the patient elected abortion.
SUMMARY
The collected and analyzed data of 152 ai
niocenteses performed at Monmouth Medical Cent
indicate the high degree of safety of the method (or
1 complication in 152 cases) when the procedure
performed on justified cases (98 percent in our stuc
at the indicated gestational age (98.1 percent in o
group). Also, it indicated the high degree of success
performing the procedure in order to obtain amnio!
fluid. In our group only 3.3 percent the tap was dry ai
only 7.1 percent of the obtained amniotic fluid w
slightly bloody.
REFERENCES
1. Broome DL. Wilson MG, Weiss B. et al.: Needle puncti
of fetus: A complication of second-trimester amniocentes
Am J Obstet Gynecol 126:247, 1976.
2. Cambell Stuart MB: Early prenatal diagnosis of neu
tube defects by ultrasound. Clin Obstet Gynecol 20:35 l -3f
1977.
3. Chandra P. Nitowsky HM, Marion R et al.: Experier
with sonography as an adjunct to amniocentesis for prena;
diagnosis of fetal genetic disorders. Am J Obstet Gynei i
133:519, 1979.
4. Danford ND: Obstetrics and Gynecology. 4th EditU\
New York, NY, Harper and Row, 1982.
5. Golbus SM: Ultrasonography in Obstetrics a
Gynecology. Philadelphia, PA, W.B. Saunders, 1983.
6. NICHD National Registry for Amniocentesis Stu!
Group: Midtrimester amniocentesis for prenatal diagnos
safety and accuracy. JAMA 236:1471, 1976.
TABLE 3
Amniocentesis
Attempts
Attempts
No.
%
Gestational Week
15
16
17
18 19
20
20+
1st
136
89.4
4
6
65
41 18
1
1
2nd
9
5.3
2
4
3
3rd
2
1.4
1
1
Dry
5
3.3
2
4
1
ji
868
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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)L. 81— NUMBER 10— OCTOBER 1984
869
Microsurgical Resection of AV Malformations
from Vital Areas of the Brain
OTAKAR R. HUBSCHMANN, M.D., AND ABBOTT J. KRIEGER, M.D., NEWARK*
Cerebral arteriovenous malformations may cause spontaneous
intracerebral hemorrhage resulting in death or severe disability .
Modem microsurgical techniques and neuroanesthesia allow for
the resection ofAVMsfrom vital areas of the brain without an
increase in neurological deficit as a result of surgery.
Arteriovenous malformations
(AVM) of the brain are one of
several causes of a spontaneous
intracerebral hemorrhage. Unlike the more common
spontaneous hypertensive hemorrhage or ruptured
aneurysm, the presence of AVM often is heralded by
recurrent headaches or seizures prior to rupture.1 The
importance of recognizing these “warning" symptoms
has increased recently as new microsurgical tech-
niques allow the resection of AVMs prior to their rup-
ture even from areas previously considered inoperable.
The surgical resection of these lesions has attained
even greater significance recently since it has been
recognized that, in addition to a life-threatening in-
tracerebral hemorrhage, a dementia-like syndrome,
thought to be caused by the pulsatile force of the AVM.
relative ischemia of the normal brain in the vicinity
caused by the shunting of blood through the AVM, or
both, add to the total disability over a period of years.
The new aggressive approach to the treatment
adopted at our institution has been directed not only
to AVMs located in the "silent" areas, but also to those
located in critical areas of the brain. Our experience,
along with that of others who have adopted a similar
approach, indicates that resectioning of an AVM from
a vital area can be accomplished with no mortality and
little additional morbidity.2
This report describes our experience with seven pa-
tients who have been operated on successfully using
870
modem microsurgical techniques, some of which he
been developed at our institution.
MATERIALS AND METHODS
Seven patients with cerebral arteriovems
malformation (AVMs) in the motor area (3), the spei
area (3), and the close vicinity of the internal eapsie
(1) were operated on. All patients were followed ba
neurologist both pre- and postoperatively. P<|
operative angiograms demonstrating a total resect a
of the AVM were performed on each patient and •
viewed by a neuroradiologist. Age, sex, location of e
AVM, and postoperative results at six months are siJ
marized in the Table. The following are case repcjs
on four of these patients.
CASE REPORT 1
A 33-year-old, right-handed male presented wit a
history of several years of headaches and seizures, cjd:
a recent subarachnoid hemorrhage which nece'i-
tated his admission.
He had only a mild hemiparesis (4/5) in the proxirii
muscles of the upper right extremity, hyperrefleJ.
and minimal spasticity. There was, however, a sigrji-
*Dr. Hubschmann is Associate Professor and Dr. Kriege s
Professor and Chief, Section of Neurological Surgery. UMDp
New Jersey Medical School. Newark. Correspondence may
addressed to Dr. Hubschmann, UMDNJ-New Jersey Medil
School. 100 Bergen Street. M.S.B.H.-592. Newark. NJ 0713.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERfV
igure 1 — The arterial phase of cerebral angiogram showing an AVM located within the motor strip (left). The schematic
rawing of the somatotopic representation within the motor strip is on the right.
'Igure 2 — Preoperative angiogram of the same patient on the left showing the AVM. On the right is a postoperative
ingiogram showing a total resection of the AVM and preservation of normal cerebral vasculature.
it degree of functional impairment of the hand,
• “cifieally, clumsiness of the fingers and thumb dur-
1; rapid alternating movements. The angiogram re-
ds the relationship of the AVM to the motor strip
Figure 1. A total resection of the AVM was achieved
gure 2). After surgery, the patient exhibited a total
niplegia of the arm, the face, and the leg, although
was fully awake. The initial return of function began
the legs and proximal muscles of the upper extremi-
bn the fourth day; in two weeks, the patient was able
walk with minimal assistance and lift the arm about
lj5. At six weeks, he had findings similar to the
‘operative ones except for the hand function which
nained severely impaired although he could use the
nd to feed himself. At six months, his neurological
■ imination was virtually the same as preoperatively,
hough the hyperreflexia and the spasticity were
mewhat greater than before surgery.
CASE REPORT 2
A 32-year-old black female was admitted after the
sudden onset of severe headaches and the rapid de-
velopment of a flaccid left lower extremity monoplegia
with only minimal drift of the left upper extremity and
total sparing of the face. A CT brain scan showed a
hematoma in the medial aspect of the hemisphere and
an AVM.
At surgery, the main draining vein was followed to
the arterial portion of the lesion and the whole AVM
was identified and totally resected. After surgery, the
patient awoke rapidly with a total hemiplegia on the
left including face, arm, and leg equally. The full return
of function to the face and the upper extremity was
complete within 24 hours and she could walk unaided
in two weeks. At six months, her findings were limited
to a minimal weakness of the lower extremities,
L. 81— NUMBER 10— OCTOBER 1984
871
Figure 3— Cerebral angiogram showing an AVM located in the receptive speech area (left). An anatomical drawing of tl
reported speech area is presented to the right (from case report 3).
Figure 4 — CT brain scan showing a large AVM in the left
temporal lobe.
characterized primarily by a 5/5 left ileopsoas weak-
ness, hyperreflexia, and an upgoing toe on that side.
Functionally, there was only a barely noticeable limp.
CASE REPORT 3
A 52-year-old female with a long history of headaches
and seizures had a positive CT brain scan during a
routine evaluation. Examination was entirely normal
including bedside testing for aphasia. The spinal fluid
was normal. Cerebral angiogram revealed a large AVM
located in the left posterior part of the middle and
superior temporal gyrus, extending toward the angular
gyrus (Figure 3). At surgery, a total resection of the
872
AVM was achieved. The patient woke promptly fl
anesthesia with no neurological deficit. Bedside t!|
ing for aphasia on the second postoperative day 's
unchanged from preoperatively. She remai c
asymptomatic at sfx months followup.
CASE REPORT 4
A 58-year-old man had a history of several year
headaches and seizures that recently had increase!
frequency. CT brain scan demonstrated a large A
located in the left posterior temporal lobe (Figure |
Cerebral angiogram confirmed the presence of an c-
tensive AVM in the temporal and parietal lobes. Til
removal of the AVM was achieved. Postoperatively, I
patient did well; he was afebrile but had a signifies
receptive dysphasia. CT brain scan showed evidenc
postoperative swelling which persisted for sevij
weeks. The dysphasia gradually improved. Six we:
after surgery, a drainage from the wound occurred. 1
cultures were positive and the infected bone flap ij
removed. At surgery, an epidural collection of pus c<
municating with a small intracerebral extension, \n
evacuated and he was treated with intravenous aJ
biotics. Postoperatively, his dysphasia rapidly il
proved. Four months later, he was readmitted foil
cranioplasty. His postoperative course was uneventl
The cosmetic results were excellent. There was o
evidence of dysphasia or any other neurological ,i-
pairment at the time of discharge.
DISCUSSION
Ruptured cerebral arteriovenous malformatk si
(AVMs) may cause a devastating neurological defiJ
from local brain destruction or death. On oceasii.
unruptured AVMs may cause, in addition to seizus
and/or headaches, a progressive dementia-like si|
drome usually ascribed to a relative ischemia of e
brain which is caused by a diversion of blood from e
normal brain into an AVM. The mortality and morbii-
tv of an AVM is greatest when it is located in vital arns
since even a small hemorrhage, well tolerated in sill
areas, may lead to a devastating neurological defi t.
The likelihood of bleeding causing serious neurologi il
problems or death increases markedly when the cu-
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSf
TABLE
Patient Results*
Age
(years)
Sex
Preoperative Symptoms
46
F
TIA. speech arrest, SAH
42
M
SAH. transient
expressive aphasia
12
M
Intracerebral hematoma,
aphasia complete right
hemiplegia, and coma
32
M
TIAs. SAH. 4/5 right
hemiparesis
28
F
Intracerebral hematoma
right lower extremity
monoplegia mild (5/5)
right upper extremity
paresis
58
M
Intracerebral hematoma
left hemiplegia coma
56
M
Seizures, headaches
Location of AVM
Postoperative
(Six-month activity)
Left angular-middle
temporal gyrus
No deficit,
normal activity
Left middle
frontal gyrus
No deficit,
normal activity
Left middle
frontal gyms
No dysphasia on
routine testing,
mild right hemi-
paresis, attends
school and plays
soccer
Left motor
cortex
Mild right hemi-
paresis (4/5A L).
unemployed,
normal recrea-
tional activity
Left motor
cortex
Minimal (5/5)
low extremity
monoparesis,
unemployed,
drug addict,
normal recrea-
tional activity
Right motor
cortex
Left hemiparesis,
2/5 left upper and
4/5 left lower
extremities
Left temporal lobe
Asymptomatic.
No asphasia
TIA: transient ischemic attack: SAH: subarachnoid hemorrhage.
‘Grading system = 5/5: full strength: 0/5: total inability to move.
iition exists in a young patient with a longer life expec-
incy. The best candidates for surgery are those where
)ie risks are the greatest, i.e. young people with AVMs
1 vital areas who can be operated on prior to their
|ieeding.
Since the danger of bleeding from an AVM persists
Iith its incomplete obliteration, often the case with
nbolization treatment, a complete surgical excision
; the ideal treatment of choice.
Incomplete obliteration often is the ease with em-
olization, partieularily when multiple feeders are sup-
lying the AVM. During embolization, small particles
r rapidly setting glues, either alone or in combination,
re used. A catheterization of the main feeding vessels
as become possible in the hands of a few experts in
Tis country and abroad. The high velocity flow
Trough the AVM assures that initially all the particles
nter the AVM. Once a significant portion of the AVM
> obliterated, however, the flow relationships change
nd at some point the flow through the AVM is not
ignifieantly different than through the normal brain,
his may result in the ability to occlude only the main
?eder as subsequent injections of the embolizing
ubstanee may result in occlusion of normal vessels.
Infortunately, incompletely obliterated AVMs are
mown to regrow and their partial occlusion does not
lessen the risk of a bleed.
Although surgical results in the past always have not
efleeted the expectations based on the pathological
analysis. McCormick and others have pointed out that
there is a strong theoretical basis for a total resectabili-
ty of most AVMs, regardless of their location.3
The AVMs are congenital anomalies resulting from
the lack of development of a capillary interface between
the arteries and veins. As a result, there is a markedly
decreased resistance to the blood flow in the system
which results in shunting of blood from normal areas
producing a separate high flow-low resistance system
in the AVM. This contributes to continuous enlarge-
ment of this system throughout a lifetime, and leads
to a rupture and bleeding which is the primary cause
of mortality and morbidity. The main vessels supplying
the AVM usually do not supply normal brain struc-
tures and conversely, normal brain tissue, usually is
not present within an AVM. McCormick has shown
that abnormal neurons and increased glial population
are sometimes found within the AVM while a plane of
gliotic sear, often laden with hemosiderin, separates
the AVM from normal brain tissue. Theoretically, an
AVM safely can be resected if the surgeon is able to
obliterate only the vessels supplying the AVM without
occluding the normal vessels in the vicinity, and
providing the resection is within the gliotic plane sur-
rounding the AVM. Despite the sound theoretical base
for a successful surgical resection, surgery for AVMs
remains a formidable task and should be performed
by experienced microvascular neurosurgeons at in-
stitutions with adequate technological support.
I'OL. 81— NUMBER 10— OCTOBER 1984
873
Our results, and those of others, indicate that resec-
tion, even of formidable AVMs, can be accomplished
without mortality and without producing significant
long-term morbidity. The neurological deficit that all
patients (with the exception of one) experienced after
surgery lasted between 24 hours and seven days, and
eventually disappeared in all. This was caused by the
cellular dysfunction of the cortical cells induced by the
necessary mechanical manipulation at surgery, rather
than by an injury to important vascular structures.
None of the patients has a neurological deficit that was
worse after surgery than preoperatively and several, in
whom there was a deficit due to hematoma, improved
dramatically postoperatively.
Based on our results, and the increasing number of
excellent results of surgical resections of AVMs from
vital areas of the brain as reported in the literature.
we feel that an aggressive surgical approach is i
dicated in carefully selected AVMs. With the increase
technical ability of neurosurgeons specializing -
microsurgeiy and improved preoperative and pc
operative support, more and more patients who und-
go operative resection of an AVM will have excelln
results which will eliminate the ever-present dangeiiift
a neurological deficit or death caused by a sudc
rupture of an unoperated AVM.
REFERENCES
1. Stein BM, Wolpert SM: Arteriovenous malformation: ii
the brain Arch Neurol 37:1-5, 1980.
2. Kune Z: Surgery of arteriovenous malformations in t
speech and motor-sensory regions. J Neurosurg 40:293-ci.
1979.
3. McCormick WF: The pathology of vascular ("artei
venous") malformations. J Neurosurg 24:807-816. 1966.
874
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS f
Effects of AIDS on Various
^spects of Blood Banking
lERCY KURIYAN, M.D., FREDERICK MUSCHENHEIM, M.D., CELSO BIANCO, M.D., NEW BRUNSWICK*
leports about acquired immunodeficiency syndrome (AIDS) have
caused anxiety in prospective recipients of blood and blood
products. Physicians should remember that the risk of AIDS from
ransfusion is much smaller than that of other known risks .
Judicial use of blood and blood components and encouraging
lealthy individuals to donate are the preventive measures .
Information and misinformation
about acquired immunodefi-
ciency syndrome (AIDS), a dis-
: e of unknown etiology, has been reported by the
i dia. This has resulted in widespread anxiety in pro-
active recipients of blood transfusions and even has
e to misconceptions regarding the safety of blood
liations.
1 ARS OF AIDS IN DONOR RECIPIENTS
t Roper organization survey of a nationwide rep-
entative sample of 2,000 adults, age 18 and over,
1 ealed that 50 percent of the survey population be-
ifes that receiving a blood transfusion can cause
'OS. The poll also found that nearly one in four
lerieans questioned incorrectly thinks that donat-
| blood for transfusion to a blood bank can cause
!pS.'
SK OF AIDS FROM BLOOD AND ITS PRODUCTS
-pidemiologie data suggest that there may be some
k of transmitting AIDS by transfusion of blood or
components. AIDS has occurred in patients with
nophilia. Seventeen cases among the approximately
l 000 such patients in the United States have been
' orted.2 The hemophiliac patients who contracted
OS all had been treated with large doses of eom-
rcially prepared factor VIII concentrates derived
; lost exclusively from paid donors numbering many
>usands for each lot. Studies have shown reduction
of T helper/T suppressor cell ratios in patients receiv-
ing lyophilized concentrate, but not in patients treated
with cryopreeipitated antihemophiliac globulin
prepared from single volunteer donors.35 However,
more recent surveys indicate that a large number of
persons with hemophilia regardless of the source of
factor VIII have abnormalities of helper/suppressor
ratios. Transfusion of blood or components from single
donors also have been suspected in the transmission
of AIDS. Reports of 15 AIDS cases in adult transfusion
recipients who are not members of the high-risk group
and which comprise 1 percent of total AIDS cases now
are under investigation.67 In these cases, diagnosis
was made one to three years after transfusion with a
median of 18 months. The number of donors per pa-
tient ranged from 2 to 42 with a median of 20 donors
per AIDS patient. In 7 of these cases, 1 of the donors
either belonged to a high-risk group or had low T
helper/T suppressor ratios. Control studies have not
yet been performed. However, in none of these cases
has a blood donor with AIDS been identified. The only
case of transfusion-associated AIDS was described in
a 20-month old infant who received a unit of platelets
from a donor who developed AIDS 7 months after
*Dr. Kuriyan is Director, New Jersey Blood Services; Dr.
Muschenheim is Director of Laboratories, Oneida Hospital,
New York; and Dr. Bianco is Director of Research and Develop-
ment, Greater New York Blood Program. Correspondence may
be addressed to Dr. Kuriyan, New Jersey Blood Services, 5-
A Joyce Kilmer Avenue, New Brunswick. NJ 08901.
L. 81— NUMBER 10— OCTOBER 1984
875
donating blood. The child underwent multiple double-
exchange transfusions for hemolytic disease of the
newborn, and received blood and blood products from
19 donors.8
Blood, platelet, and fresh frozen plasma transfusions
from volunteer donors have not been linked definitely
to the development of AIDS in any of the more than
15 million transfusion recipients in the United States
in the past three years. About 98 percent of the whole
blood or blood components used for transfusion in the
United States and 100 percent of that used in New
Jersey come from volunteer donors.9
PRECAUTIONS IN BLOOD COLLECTION
To prevent possible transmission of AIDS by blood
and its products, blood collection agencies around the
country, including New Jersey, have instituted several
public health measures based on recommendations of
the United States Public Health Service.10 These in-
clude educational programs to infonn persons at high
risk of AIDS to refrain from blood or plasma donations
(Table 1 ). Medical screening of donors has been ex-
tended to exclude anyone with signs or symptoms as-
sociated with AIDS (Table 2). This has resulted in a
2 percent increase in donor deferral by medical history.
The Greater New York Blood Program and its divisions
have a unit-exclusion system which permits individ-
uals in the high-risk group to designate their blood for
research. Every donor is given a confidential form
which summarizes current information on AIDS and
lists the high-risk groups. The form allows him or her
to confidentially designate their donation for research
only and not for transfusion. These units, as well as
those from donors who left the form blank are removed
from inventory and are not distributed to hospitals.
About 1.2 percent of persons who donated in New Jer-
sey through this program over an eight-month period
specified that their blood be used for research only.
Individuals at high risk of exposure to AIDS have been
most cooperative in voluntarily withholding their
donation of blood for transfusion.
SURROGATE TESTING
No test yet has been found that reliably can screen
blood donors for exposure to AIDS. One recent study
suggests that acid-labile alpha interferon might prove
to be an identifying marker in asymptomatic pa-
tients.11 Other nonspecific tests to identify blood
donors at risk for AIDS currently being evaluated in-
clude antibodies to core antigen of hepatitis B virus,
antibodies to cytomegalovirus (CMV), T helper/ T sup-
pressor cell ratios, alpha thymosin, and Beta 2 micro-
globulin. These assays have been found abnormal in
AIDS patients and some high-risk groups. However,
none has been shown to detect a possible carrier state
for AIDS.
PRECAUTIONS IN BLOOD USAGE
Additional caution in the use of blood and blood
products by treating physicians is necessary when
considering the known risks of transfusion (hepatitis,
cytomegalovirus, malaria and hemolytic reactions)
and those under investigation, e.g. AIDS.
In mild hemophiliacs, ciyoprecipitate is being rec-
ommended for use in factor replacement therapy.12
TABLE 1
Persons at High Risk*
1
Risk Groups for AIDS
Cases
% o
Toti
Homosexual or bisexual males
1909
71.:
IV drug user, no history of
homosexuality
460
17.:
Haitian, no history of homosexuality or
drug use
131
4.<
Hemophiliac
17
O.f
Other
161
6.(
‘AIDS: Weekly Surveillance Report. CDC, November 7
1983. .
TABLE 2
AIDS— Related Donor Medical Screening*
1. Ann inspection and questioning for intravenous dr
use
2. History of AIDS
3. Cough or upper respiratory infection
4. Persistent recurrent night sweats
5. Lymph node enlargement
6. Tumor-like nodules or lumps on skin
7. Persistent diarrhea
8. Fever
9. Unexplained weight loss
‘Donors with a positive response are deferred.
TABLE 3
Requisites for Autologous Transfusion
1 . Autologous transfusion request from physician
2. Written consent by donor-patient
3. Donor hemoglobin level of 1 1 g/dl or greater
4. Oral iron supplements when multiple phlebotomies
needed
5. Identification tags for blood and components
6. Communication protocols to notify physician or
hospital of presurgical autologous blood availability
TABLE 4
Hazards of Transfusion
Hemolytic reaction
Nonhemolytic reaction
Hypersensitivity dermal
reactions
Anaphylaxis, severe
Hepatitis B*
Malaria
1 in 2,500 to 4,500
1 to 3 percent frequen
3 percent of transfusi
Less than 1 in 20,000
74 per million
4.9 per million
Acquired immunodeficiency syndrome**
Hemophiliac plus blood 1 per million
transfusion
Blood transfusion only 1 in 2 million
*MMWR. May 1983 (approximate estimate based on car
of hepatitis B reported post-transfusion), p. 2355.
“Forum— views and opinions, Bruce A. Lenes. CCBC
Newsletter, June 10, 1983, p. 6.
876
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JEF %
Jactor VIII concentrates continue to be the mode of
lerapy for severe hemophilia. All elective surgical
rocedures in these patients need to be evaluated with
'spect to advantages and disadvantages of delay. A
ew heat-treated factor VIII concentrate (Hemophil T)
as been licensed recently. This process may reduce
le hepatitis risk associated with these derivatives but
is unknown whether it will change the AIDS risk.
UTOLOGOUS DONATION
Autologous blood transfusion, especially for elective
lirgery, has been encouraged (Table 3). The use of
itologous blood is ideal but feasible only in patients
ho probably will not require much blood and whose
palth status permits blood donations. Generally,
ood for autologous donation is taken from patients
ith hematocrit of 34 percent ( 1 1 gm of hemoglobin)
- higher, and at a frequency of about one unit per
eek. Plastic, orthopedic, gynecological, and general
jrgery (e.g. cholecystectomy, mastectomy, or
'ostatectomy) are elective procedures for which dona-
ton from self is useful. Intraoperative and post-
nerative salvage using commercially available auto-
ansfusion units have applications in elective
qscular surgery and trauma cases.
ESIGNATED OR DIRECTED DONATIONS
Requests for use of donors selected by the potential
jcipient has been a sequela to the fear surrounding
!DS. However, the major blood banking organiza-
jons — the American Association of Blood Banks
ABB), the American National Red Cross (ANRC), and
ie Council of Community Blood Centers (CCBC) — in
joint statement “strongly recommended that directed
pnations programs not be conducted." There is no
'ssurance that such programs increase the safety of
ood. Patient-selected donors are under pressure to
ve blood and may not be as truthful about their
embership in a high-risk group as a volunteer, un-
immitted donor. In addition, directed donations may
srupt a smoothly functioning blood system.
EW JERSEY STATUS
The Blood Bank Task Force for New Jersey along
ith the New Jersey Department of Health and Blood
ank Association issued a similar statement dis-
couraging directed donations.13 They further con-
cluded that available data support the fact that AIDS
is not being spread by blood transfusion from volun-
teer donors, and that appropriate public health
measures have been instituted by the region’s blood
collection facilities to protect the quality of the regional
blood supply.
CONCLUSION
The practicing physician should remember that the
risk of AIDS from transfusion is much smaller than
that of the other potential risks (Table 4). Judicious
use of blood and blood components and encourage-
ment of the healthy individual to donate are the best
preventive measures available.
REFERENCES
1. Roper Organization Poll, August 13-20, 1983.
2. Acquired Immunodeficiency Syndrome (AIDS): Weekly
surveillance report, AIDS Activity, Center for Infectious Dis-
ease, Centers for Disease Control, November 7, 1983.
3. Lederman MM, Ratnoff OD, Schillian JJ, Jones PK,
Sehacter B: Impaired cell-mediated immunity in patients
with classic hemophilia N Engl J Med 308:79-82, 1983.
4. Menitove JE, Aster RH, Casper JT, et al.: T-lymphoeyte
subpopulations in patients with classic hemophilia treated
with cryoprecipitate and lyophilized concentrates. N Engl J
Med 308:83-86, 1983.
5. Goldsmith JC, et al.: T-lymphocyte subpopulation ab-
normalities apparently in healthy patients with hemophilia.
Ann Intern Med 98:294-296, 1983.
6. Update: AIDS. United States Morbidity & Mortality
Weekly Report September 9, 1983.
7. Jett JR Kuritsky JN, Katzmann JA Homburger HA: Ac-
quired immunodeficiency syndrome associated with product
transfusion. Ann Intern Med 99:621-624, 1983.
8. Ammann AJ, Cowan, MJ, Wara DW, Weintrub P, Dutz
S, Goldman H, Perkins HA: Acquired immunodeficiency in an
infant: Possible transmission by means of blood products.
Lancet 98:956-958, 1983.
9. State of New Jersey Department of Health: 1982
Statistical Summary of Blood Use in New Jersey.
10. Petriccian JC: Letter to all establishments collecting
human blood for transfusion. Office of Biologies, FDA March
24, 1983.
11. ME Eyster, et al.: Acid-labile alpha interferon; a pos-
sible preclinical marker for acquired immunodeficiency syn-
drome in hemophiliacs. N Engl J Med 309:583, 1983.
12. The National Hemophilia Foundation Medical and
Scientific Advisory Council, January 14, 1983.
13. Statement of Blood Bank Task Force of New Jersey,
June 30, 1983.
>L. 81— NUMBER 10— OCTOBER 1984
877
Androgen-Secreting Ovarian Tumors in
Postmenopausal Women
William B. Ober. m.d., Hackensack*
Two patients with lipid cell tumors of the ovary demonstrate that
radioimmunoassay for total serum testosterone is the best
laboratory clue to androgenization and that radiologic studies
may miss small ovarian tumors. The expense of endocrine testing
requires physicians to select the tests most likely to provide
decisive information.
The clinical syndrome of an-
drogenization generally is well
recognized. Such signs and
symptoms as hirsutism, acne, temporal hair recession,
hypertrophy of the clitoris, and a lowered tessitura are
the effects of excess circulating androgen, chiefly
testosterone, converted peripherally to dihydrotestos-
terone by 5-alpha-reduetase at the target organs. In
prepubertal girls and premenopausal women, the
diagnostic possibilities are numerous, including
micropolycystic ovaries, ovarian hyperthecosis, hyper-
plasia of the adrenal cortex, and other complex en-
docrine syndromes. In postmenopausal women, excess
testosterone production virtually is limited to patients
with benign or malignant adrenocortical tumors or
with a few histological types of ovarian tumor that
usually are benign. That exceptions occur should be
noted: an androgenic thecoma,1 a Krukenberg tumor
metastatic from the colon or stomach with luteinized
stroma,2 and reports of other unexpected lesions.
Given today’s techniques for testing steroid
hormones and their metabolites and radiological tech-
niques for localizing lesions, it seems possible to de-
velop a simplified, cost-effective plan for investigating
postmenopausal women who are androgenized and for
determining the appropriate surgical approach.
CASE REPORT 1
A 71 -year-old woman complained of hirsutism de-
veloping slowly over two years. Coarse dark hair fii
appeared on the face; it grew slowly at first, then mo
rapidly to the point where electrolysis was necessa
During the previous six months, dark hair began
appear on the chest. Neither recession of the hairli
at the temples nor acne was present. Menarche beg
at age 15, and menses were regular. She had sever'
pregnancies, none of which were carried to ten
Menopause was at age 50 and without complicatior
Physical examination was normal except for slig
enlargement of the clitoris. Abdominal hair was
creased over both lower quadrants. Table 1 lists e
docrine determinations. Bimanual pelvic examinatic
disclosed a small mobile uterus; no adnexal mass w;
felt. A pelvic sonogram was normal. A CAT scan showr
normal adrenal glands. At laparotomy, the uterus w;
small and the ovaries were normal for age. No gro:
tumor was seen. Total abdominal hysterectomy ari
bilateral salpingo-oophoreetomy were carried out. T1
right ovary measured 2.5 x 1.8 x 0.8 cm, and in ■'
medulla was a spherical 1.4 cm, soft brown tumcj
sharply circumscribed from the cortex which conf
pletely surrounded it. Microscopic examinatic
showed it to be composed of an admixture of mediun
*Dr. Ober is Director Emeritus, Department of Laboratorie
Hackensack Medical Center. Correspondence may be a;
dressed to Dr. Ober, Hackensack Medical Center, Departme:
of Pathology, Hackensack, NJ 07601.
878
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
tudy
erum testosterone
TABLE 1
Endocrine Determinations
Value
326 ng/dl
Normal Range
10 to 75
lasma DHEA-S
1 13 mcg/dl
50 to 230
SH
59 MlU/ml
2 to 22
H
48 MlU/ml
22 to 133
rolactin
4.3 ng/ml
6 to 30
SH
8 MU/ml
1 to 10
4
8.2 mcg/dl
4 to 13
j3 uptake
42%
24 to 36
;stradiol
8.8 ng/dl
3 to 5
4-hour urinary
ree cortisol
44 mcg/dl
20 to 90
TABLE 2
Endocrine Determinations
itudy
Value
Normal Range
ierum testosterone 379 ng/dl
20 to 150
•’lasma DHEA-S
380 mcg/dl
1 10 to 610
'SH
77 MlU/ml
40 to 200
—
’rolactin
—
j'SH
1.7 MU/ml
0 to 4.5
4
7 mcg/dl
4.5 to 12.5
'3 uptake
28%
23 to 34
Estradiol
;
—
Ierum cortisol,
2.00 P.M.
13.5 mcg/dl
A.M. 7 to 25
P.M. 2 to 9
?ed polyhedral cells with bright eosinophilic
itoplasm and larger polyhedral cells with clear
toplasm (Figure 1). The former resembled luteinized
lls; the latter resembled adrenocortical cells. Oc-
sional transitional cells were seen. Crystalloids of
'inke were not identified. The overlying circumfer-
jitial cortex was slightly thickened and hypercellular.
pe tumor was classified as a lipid cell tumor, stromal
teoma type. Significant lesions were not present in
e other organs.
• One week after the operation the serum testosterone
|/el was 38 ng/dl (normal, 10 to 75 ng).
VSE REPORT 2
A 61 -year-old woman complained of hoarseness that
ltd not been relieved by cough syrup. Her regular
iiysician recognized that the hoarseness represented
‘lowering of her tessitura. She had been in good gen-
al health except for a cholecystectomy two years
eviously. Menarche had occurred at age 1 1 '4 and
Tnses were regular. She was a gravida 3, para 3.
enopause had occurred at age 53 and was aecom-
tnied by moderate metrorrhagia.
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Figure 1 — The ovarian tumor (case report 1) is composed of
a mixture of small polyhedral cells with bright eosinophilic
cytoplasm and large cells with foamy, finely vacuolated
cytoplasm. Hematoxylin-eosin, 240 x.
Physical examination disclosed facial hirsutism and
new growth of hair along the linea alba lower ab-
domen, and upper thighs. The clitoris was con-
spicuously enlarged. The uterus was small and mobile;
no adnexal mass was palpable. A pelvic sonogram was
normal, and a CAT scan showed no enlargement of the
adrenal glands. Table 2 lists endocrine determinations.
At laparotomy, the uterus contained a leiomyoma,
and the tubes and ovaries were normal for age. Total
abdominal hysterectomy and bilateral salpingo-
oophorectomy were carried out. The left ovary
measured 1.8 x 1.5 x 0.8 cm and contained a 1 cm
discrete brown-tan nodule in its center. Microscopic
examination revealed it to be composed of medium-
sized polyhedral cells with eosinophilic cytoplasm and
distinct cell membranes. A few cells contained small
vacuoles in the cytoplasm and a few cells were large,
polyhedral, and had a clear cytoplasm resembling
adrenocortical cells. A fine capillary network was pres-
ent. Crystalloids of Reinke were not found. The lesion
was classified as a lipid cell tumor. The myometrium
contained several medium-sized leiomyomata, and the
endometrium was atrophic. No significant changes
were seen in the other structures (Figure 2).
CLINICAL CONSIDERATIONS
Approximately 75 percent of women over 60 have an
increased amount of hair on the upper lip or chin
which is hypertrichosis, not clinical hirsutism. r’ The
increase in hair is slight to moderate and stable. It is
not accompanied by other signs of excess androgen
production and is a cosmetic rather than a medical
problem. Blood and urine androgens may be at or near
)L. 81— NUMBER 10— OCTOBER 1984
879
Figure 2 — The ovarian tumor (case report 2) is composed of
medium-sized polyhedral cells with finely vacuolated
cytoplasm. Hematoxylin-eosin, 240 x.
the upper limit of normal for age, perhaps the result
of ovarian cortico-stromal hyperplasia or post-
menopausal increase in the number of ovarian hilus
cells. Clinically significant hirsutism is progressive,
albeit the rate of progression may be slow; sooner or
later, it is accompanied by one or another physical sign
of androgenization. Serum testosterone in such pa-
tients usually is elevated to double the upper limit of
normal or higher and often is well into the male range.
Patients react variably to progressive hirsutism. It
usually has been present for several months, often over
a year, before they seek medical attention. In case re-
port 2, the patient consulted her doctor because she
thought she was hoarse, though her degree of
hirsutism was greater than in case report 1.
The problem facing the clinician is to decide whether
the source of increased testosterone is ovarian or
adrenal. Hyperthyroidism is not accompanied by
hirsutism; onlyjuvenile patients with hypothyroidism
are hirsute, and then only to a minor degree. Some
patients with Cushing’s syndrome may be hirsute, but
hypertension, plethora, and body habitus serve as
ready points of distinction between that entity and
androgenization from an ovarian or adrenocortical
tumor. With few exceptions, an elevated serum
testosterone level in a postmenopausal woman limits
the diagnosis to a tumor of either of those two organs.
In prepubertal girls and women in the reproductive
age, the range of diagnostic possibilities is wider and
subtle alterations in the kinetics of androgen
metabolism may be present.4 Studies of production
rate and metabolic clearance may be valuable in such
patients. Selective sampling by catheterization of ovar-
ian and adrenal veins and determination
testosterone and androstenedione gradients may yie
useful information in these younger women wi
clinical androgenization.
If case reports in the literature are any guide,
appears that although androgen-secreting tumors
the ovary are uncommon, androgen-secreting tumo
of the adrenal cortex are rare. It is not feasible to assij
numerical values to their relative frequency but, giv<
a postmenopausal woman with an androgen-seeretii
tumor, the greater probability is that it will be local
in an ovary. Radiologic and laboratory investigation
such patients should be designed to exclude
adrenocortical tumor. Physical examination may n
be helpful since most adrenal tumors are not lari
enough to present as a flank mass and only about h;
the androgenic ovarian tumors can be palpated r(
bimanual pelvic examination.
Adenomas and carcinomas of the adrenal cortex mi
occur at any age from infancy to old age. Fewer th;
15 percent of them occur in postmenopausal wome|
Estrogen-secreting tumors produce precocious pubr
ty in girls, menstrual irregularities in adult wome
and gynecomastia in males. Androgen-seeretii
tumors produce precocious puberty in boys; t
tumors are clinically inconspicuous in adult mal<
and produce the androgenization syndrome in femal
irrespective of age. About 25 percent of adrenocortic
carcinomas secrete enough androgen to produce e
docrine signs and symptoms.56
Androgen-secreting ovarian tumors likewise c
occur at any age. The Sertoli-Leydig cell tumor is me
frequent in younger than in older women, but abo
40 percent of the varieties of lipid cell tumor occur
postmenopausal women.16
PATHOLOGIC CONSIDERATIONS
The archetypal adrenocortical adenoma is an e
capsulated spherical or ovoid nodule with a soft yelli
to yellow-brown cut surface. The majority are over
cm in diameter. They may weigh from 50 gm to o\
1,000 gm. Microscopic examination usually reve;
polyhedral cells that closely resemble cells of t
adrenal cortex with clear or vacuolated cytoplasm ai
well-defined cell membranes, arranged in a variety
patterns. In a minority of specimens, bizarre cells wi
hyperchromatic nuclei and an increased mitotic n
are seen, and venous invasion may be demonstrab
It is tempting to consider this as evidence of mal
nancy but, in the majority of such exampf
metastasis does not occur. One of the recurrent pre
lems in endocrine neoplasms is to distinguish betwe
adenomatous hyperplasia versus true adenoma ai
between adenomas with cell atypia versus trj
carcinoma. Adrenocortical carcinomas tend to
larger than adenomas with weights over 500 gm r
uncommon. Their cell population may be mixed, i
polyhedral cells resembling adrenal cortex admix
with fields of less well-differentiated cells, and with 0
usual microscopical stigmata of malignancy. Capsul
invasion and infiltration of retroperitoneal fat by poc
ly differentiated cells occurs and is good evidence
malignant potential, but metastatic deposits demc
strated at the time of operation or subsequently pre
ably are the only real proof of malignancy.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
880
Occasional examples of testosterone-secreting
idrenal tumors 4 cm in diameter or smaller have been
eported.7 10 The patients were from 20 months to 76
'ears old. In two patients, administration of HCG in-
creased androgen production.89
Primary androgen-producing tumors of the ovary es-
;entially are limited to two types, the Sertoli-Leydig cell
umor with its subtypes and the family of lipid cell
umors. Sertoli-Leydig cell tumors characteristically
ippear as rounded masses that may be yellow, orange,
ilive, brown, or variegated— the color depending on the
>roportions of neutral fat and lipochromes. They vaiy
n size from 2 cm in diameter to 10 cm or more in
liameter. The great majority occur in women under
he age of 30; only about 10 percent occur in post-
nenopausal women. Well-differentiated examples
Jmost always are benign, but Sertoli-Leydig cell
umors of intermediate or poor differentiation are
apable of producing metastatic deposits.
The family of lipid cell tumors includes adrenal rest
umors, hilus cell tumors, stromal luteomas, and pure
.eydig cell tumors without a Sertoli cell component,
because histological distinctions within this group are
lot precise, the neutral term "lipid cell tumor" has
>een recommended, though a more accurate term
night be steroid cell tumor. They appear as soft
pherieal masses sharply demarcated from surround-
ing ovarian tissue and having the same range of colors
ts Sertoli-Leydig cell tumors. Those occurring in the
iroad ligament or mesovarium may well arise from
idrenocortical rests that are common in those lo-
ations. The fact that some are associated with formes
rustres of Cushing's disease cannot be taken as
■videnee of origin in an adrenal rest, but rather reflect
he pattern of steroidogenesis in those tumors. Hilus
•ell and Leydig cell tumors can be identified specifically
>y demonstrating crystalloids of Reinke, but these in-
raeytoplasmic protein crystals are inconstant, being
ound in only 40 percent of such tumors.12 Over 60
lercent of them occur in women under the age of 50;
hey are relatively more common in postmenopausal
vomen than Sertoli-Leydig cell tumors. Only infre-
quently do lipid cell tumors exceed 6 cm in diameter;
he majority are about 2 cm to 4 cm in size. It is
mpossible to distinguish between Sertoli-Leydig cell
umor and lipid cell tumor on clinical or en-
locrinological grounds.
IADIOLOGIC CONSIDERATIONS
Radiologic localization of an androgen-secreting
umor depends on demonstrating the image of a mass.
Current CAT scan technology enables a radiologist to
lemonstrate with precision an adrenal mass as small
i 1 cm in size. Pelvic sonography can demonstrate
umors 2 cm in size that distort the contour of an
•vary. One limitation of pelvic sonography is that a
ubserosal leiomyoma of the uterus may be difficult to
listinguish from an ovarian mass. Another problem is
hat a tumor-bearing ovary may prolapse into the
>ouch of Douglas so that its image is not separable
onographieally from the uterus. The two cases pres-
nted here could not be detected by pelvic sonography
because they were small and entirely within the
•ubstanee of the ovary.
ENDOCRINE TESTING
Androgenization in a postmenopausal woman is the
effect of excess testosterone production. This best is
determined by radioimmunoassay for total serum
testosterone. Unlike its precursor androstenedione,
testosterone is not a 1 7-ketosteroid, and measuring
urinary 1 7-ketosteroids may prove misleading. Ap-
proximately 98 percent of serum testosterone is bound
to protein and the remainder is free. Although free
testosterone can be measured, elevation of total
testosterone suffices for diagnosis.
Any tumor that synthesizes testosterone can and
often does synthesize estrogens by aromatization of
the “A” ring in the steroid molecule. This is consistent
with clinical evidence for estrogen production in
adrenocortical tumors and in any of the various ov-
arian tumors mentioned. Immunohistochemical lo-
calization of steroids in Sertoli-Leydig cell tumors
showed large amounts of testosterone in Leydig cells,
less constant and smaller amounts in Sertoli cells, in-
constant amounts of estradiol and estriol in both cell
types, and even small amounts of progesterone in a few
cases.13 Any woman with elevated serum testosterone
almost is certain to have elevated estrogen levels not
only because of production in the tumor but also be-
cause of peripheral conversion of testosterone to
estrogens. Determination of estrogen levels in urine or
blood adds little information of value in an an-
drogenized postmenopausal woman. The amount of
estrogen usually is insufficient to produce cor-
nification in vaginal exfoliative cytology.
Androgenization in a post-
menopausal women is the
effect of excess testosterone
production .
It is not necessary to test thyroid function in a
clinically euthyroid patient, nor is it appropriate to
determine prolactin values in a woman without galac-
torrhea. Determination of pituitary gonadotropin
levels adds little importance to the diagnosis. Though
stimulation and suppression tests with chorionic
gonadotropin may yield interesting biologic infor-
mation about the dependency of steroid-producing
tumors, they are not of diagnostic value.
Tests of adrenocortical function in this setting are
essential. If they are within normal limits, one may be
confident that the tumor is ovarian, except for the rare
pure testosterone-secreting adrenocortical tumor. The
most sensitive and specific test of adrenal androgen
function is the plasma level of dehydroepiandrosterone
sulfate (DS or DHEA-S) by radioimmunoassay.14 In-
asmuch as over 95 percent of circulating DHEA-S is
from the adrenal cortex and less than 5 percent from
gonadal sources, a significant elevation indicates the
elevated testosterone is from the adrenal.15 Only an
occasional ovarian tumor will produce significant
amounts of DHEA-S as well as testosterone. Like radio-
immunoassay determinations of serum testosterone,
plasma DHEA-S values are highly replicable.
3L. 81— NUMBER 10— OCTOBER 1984
881
Taking into account that as many as one-third of
patients with androgen-secreting tumors may exhibit
“Cushingoid" features, i.e. signs and symptoms less
than full-blown Cushing’s disease, it is not un-
reasonable to test glucocorticoid function by either a
single determination of urinaiy-free cortisol in a 24-
hour collection or a morning/evening measurement of
serum cortisol. (In case report 2, a single mid-after-
noon serum cortisol was used. This may be less
sensitive than testing for diurnal decline, but the nor-
mal value gave reasonable assurance that adrenal
glucocorticoid function was unimpaired.) The clini-
cian must balance the inconvenience of two
venipunctures for diurnal rhythm versus the nuisance
and possible inaccuracy of collecting a 24-hour urine
specimen. Scully has seen two lipid cell tumors of the
ovary with metastases associated with florid Cushing’s
syndrome and elevated serum cortisol.16
An elegant, highly specific method of testing is retro-
grade venous catheterization with selective sampling
from each ovarian and each adrenal vein.17 18 Using this
technique, all appropriate endocrine tests can be car-
ried out at one time and the site of tumor localized.
But it is an invasive method, and there often is techni-
cal difficulty in catheterizing the right adrenal vein.
And, of course, it quadruples the cost of endocrine
testing.
COST EFFECTIVENESS
Endocrine testing is expensive so the judicious
physician will select only those tests most likely to
provide decisive diagnostic information. One should
distinguish between diagnostic tests and those that
merely provide information that is “interesting to
know." The clinical pathology laboratory is not the
place to satisfy medical curiosity at the expense of the
patient or the insurance carrier. At present, except for
special laboratories in research centers and university-
affiliated hospitals, most of the infrequently requested
endocrine tests are performed by commercial reference
laboratories. These centers are equipped to receive
specimens from widely distributed community and
voluntary hospitals as well as from doctors’ private
offices. Most practicing physicians and nonuniversity
hospitals do not have access to the specialized labora-
tories in research centers and university-affiliated hos-
pitals. Most of the analytic procedures are carried out
by radioimmunoassay. Although many community
hospital laboratories are equipped to carry out radio-
immunoassay on selected substances, the feasible
range of tests they can offer is limited by the frequency
with which they are requested. Assays for digoxin, in-
sulin, T4 , TSH, and hepatitis antigens and antibodies
frequently are requested and can be reported with
replicable results and prompt turnaround time. Tests
for polypeptide and steroid hormones, however, are
less frequently ordered. Not only is accuracy reduced
when uncommonly performed tests are carried out,
but reagent costs render it uneconomical for com-
munity hospital laboratories to offer them.
Table 3 lists the charges for the tests mentioned as
given in the fee schedules of three of the leading refer-
ence laboratories in this country. Three tests (total
serum testosterone, plasma DHEA-S, and two de-
TABLE 3
1983 Charges jor Selected Endocrine Tests by Three
Major Reference Laboratories
Labora- Labora-
tory I tory 2
.
Labora-
tory 3
Testosterone, total
$47.85
$52.00
$59.75
Testosterone, free
74.90
72.00
72.00
‘DHEA-S, + plasma
35.00
45.00
60.00
‘Cortisol, plasma++
28.00
33.50
34.50
Cortisol, free, urine
35.20
32.90
40.00
FSH
27.50
27.00
37.50
L1I
28.00
26.40
37.50
Prolactin
40.00
39.00
52.00
TSH
34.00
33.00
39.50
T3 uptake
6.95
7.50
14.00
t4
8.05
7.75
16.00
Estrogens, total
35.20
32.90
49.00
All tests except T3 uptake performed by radio
immunoassay on serum, except as stated.
+: DHEA-S = dehydroepiandrosterone sulfate.
++: Requires two specimens, one at 8:00 a m., one at 4.0(
P.M.
terminations of plasma cortisol) range in total co
from Si 38.85 to Si 88.75 with an average cost
$163.87. These are the minimum tests needed
evaluate an androgenized postmenopausal woma
Also listed in Table 3 are the prices for free testo
terone, pituitary gonadotropins, and thyroid functio
as well as total estrogens and prolactin. By not orde
ing these tests, the attending physician can save fro
$213.55 to $285.50 with an average of $243.15. It b
comes apparent that the checklist of tests offered Is
reference laboratories is an open and tempting invit
tion.
Except for the urinaiy-free cortisol assay, this di
cussion deliberately has excluded tests for pituita
and gonadal hormones on 24-hour urine specimen)
which invariably are more expensive than tests c
serum or plasma. Also, excluded is testing for estrogf
fractions because they are not relevant in women wil
androgenization. The figures provided do not take in
account the cost of obligatoiy routine urinalysi
hemogram, and automated blood chemistry pane
which are as conveniently performed in local labor
tories as in reference laboratories. No data are give
on the costs of an adrenal CAT scan or a pelvic som
gram inasmuch as they vary widely depending on ge;
graphical location.
Perhaps it is timely to recall the comment made t,
Mozart who, already an established composer at 2
first saw scores of Handel’s music in the library <
Baron van Swieten: “He achieves the greatest effect
by the simplest means."
REFERENCES
1. Case records of the Massachusetts General Hospit
case 10-1980. N Engl J Med 302:621-626, 1980.
882
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
'2. Clinico-Pathologic Conference: Knickerbocker Hospital.
' State J Med 59:1083-1090, 1959.
3. Melick R Taft HP: Observations on body hair in old
pple. J Clin Endocrinol Metab 19:1597-1607, 1959.
4. Kirschner MA Bardin CW: Androgen production and
dabolism in normal and virilized women. Metabolism
-.667-688, 1972.
> 5. Huvos AG, Hajdu SI, Brasfield RD, Foote FW Jr: Adrenal
i rtical carcinoma: Clinicopathologic study of 34 cases.
■ incer 25:354-361, 1970.
3. Hajjar RA Kickey RC, Samaan NA Adrenal cortical
Ircinoma: A study of 32 patients. Cancer 35:549-554, 1975.
7. Burr IM, Graham T, Sullivan J, Hartman WH, O'Neill J:
testosterone-secreting tumor of the adrenal producing vir-
! cation in a female infant. Lancet 2:643-644, 1973.
8. Werk EE Jr, Sholiton LJ, Kalejs L: Testosterone-secreting
Irenal adenoma under gonadotropin control. N Engl J Med
19:767-770, 1973.
9. Givens JR Andersen RN, Wiser WL, Coleman SA Fish SA:
gonadotropin-responsive adrenocortical adenoma. J Clin
idocrinol Metab 38:126-133, 1974.
10. Larson BA Vanderlaan WP, Judd HL, McCullough DL:
testosterone-producing adrenal cortical adenoma in an
lerly woman. J Clin Endocrinol Metab 42:882-887, 1976.
11. Scully RE: Tumors of the ovaiy and maldeveloped
!
i
gonads. Atlas of tumor pathology, second series, fascicle 16.
Armed Eorces Institute Pathology 190-208, 1979.
12. Taylor HB, Norris HJ: Lipid cell tumors of the ovary.
Cancer 20:1953-1962, 1967.
13. Kumian RJ, Aidrade D, Gobelsmann U. Taylor CR Im-
munohistochemical study of steroid localization in Sertoli
Leydig cell tumors of the ovaiy and testis. Cancer
42:1772-1783, 1978.
14. Korth-Schutz S, Levin LS, New MI: Dehydroepian-
drosterone sulfate (DS) levels, a rapid test for abnormal
adrenal androgen secretion. J Clin Endocrinol Metab
42:1005 1013, 1976.
15. Clinicopathologic Conference: Hirsutism progressing to
virilization in an older woman. Am J Med 70: 1255- 1 266, 1981
16. Scully RE: Personal communication.
17. Judd HL, Spore WW, Talmer LB, Rigg LA Yen SCC,
Benirschke K: Preoperative localization of a testosterone-
secreting ovarian tumor by retrograde venous catheterization
and selective sampling. Am J Obstet Gynecol 120:91-96,
1974.
18. Casthely S, Diaminidis HP, Pierre-Louis R Hilar cell
tumor of the ovary: Diagnostic value of plasma testosterone
by selective ovarian vein catheterization. Am J Obstet
Gynecol 129:108-110, 1977.
)L. 81— NUMBER 10— OCTOBER 1984
883
IMAGING:
Magnetic Resonance Imaging (MRI)*
Kenneth L. Jewel, m.d., Barry I. Loigman, m.d., Richard F. Matte rn, m.d.,
Steven D. Richman, m.d., Charles C. Royer, m.d., Charles A. Whelan, m.d., caldwell*
MRI is a new imaging modality which creates images of the head
and body in any anatomic plane without the use of ionizing
radiation or the need for intravenous contrast injection. Accepted
as the diagnostic procedure of choice to evaluate the brain and
spinal cord, the capability to image the remainder of the body
with equal accuracy is viewed with great expectation.
Computerized imaging for medi-
cal diagnosis has been the
major radiological advance of
the last decade. The integration of computer tech-
niques in x-ray computerized tomography (CT), nu-
clear medicine, real-time ultrasonography, and digital
subtraction angiography (DSA) has allowed for re-
markable improvements in diagnostic capabilities. A
recent development, computerized magnetic reso-
nance imaging (MRI), promises even greater advances
in medical imaging.
Since the first MRI images in 1973,1 rapid and sig-
nificant progress has been made, so that today’s im-
ages offer superb tomographic display with spatial res-
olution comparable to CT and unparalleled contrast
resolution. The fact that these extraordinary images
are created without the use of ionizing radiation and
without the need for intravenous contrast material,
adds considerably to the excitement and anticipation
sweeping the medical community.
The purpose of this paper is to display normal neu-
roanatomy and representative neuropathologic states
demonstrating the usefulness of clinical MRI. We
emphasize that MRI is extremely useful for imaging
the pelvis,23 liver,4 heart,5 pancreas,6 kidneys,7 adrenal
glands,8 and musculoskeletal system.9 This brief com-
munication cannot encompass the already vast litera-
ture on MRI so the interested reader is referred to the
many articles and texts on this subject.
METHOD
The magnetic resonance images displayed (Figure j
1 to 7B) are obtained on a Diasonics 0.5 Tesla supe
conductive magnet operating at a field strength of 3.
Kgauss and corresponding to a resonant frequency (
15 MHZ for hydrogen nuclei. The MR imaging systei i
is housed in a copper and aluminum-lined rooi '
specially shielded against aberrant radio waves. Th
radiofrequeney (RF) coils are saddle shaped with a 1
aperture of 25 cm for head imaging and 55 cm for bod I
imaging. Utilizing a multislice spin echo technique,
typical imaging series with a repetition time of 2.
seconds (TR = 2.0) takes approximately 1 7 minutes fc \i
20 image levels. In each plane, the first spin echo (TJ S
= 28 msec) and second echo (TE = 56 msec) ar! ■
analyzed. A typical patient study with images in coy !
onal and transaxial planes requires about 30 minute: t
Early examinations were performed as part of a Feden I *
Drug Administration (FDA) approved investigation^]
protocol. Recently, the FDA granted formal approval t |
utilize MR imaging to produce eross-seetional display
’IMAGING is a new column presented in The Journal unde
the direction of Judith K. Amorosa, M.D., Director of Medici 4
Education, Department of Radiology, UMDNJ-Rutgers Med
cal School.
’’From the Montclair Radiological Associates. Coij |
respondence may be addressed to Dr. Jewel, Montclair Radi(
logical Associates, 445 Bloomfield Avenue, Caldwell, N
07006. kn
884
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE1 0[
Figure 2A — A transaxial image demonstrates the presence of
abnormal signal in the suprasellar cistern (open arrow). The
juxtasellar internal carotid arteries as well as both orbits, lens
structure, and optic nerves are depicted clearly.
Figure 2B — A second echo sagittal image demonstrates the
T2 weighted configuration of the chromophobe adenoma The
ballooned sellar component (open arrow) and the rounded
suprasellar configuration (black arrowhead) are noted.
can be applied to most patients with neurological com-
plaints. Patients who are better studied with CT x-ray
techniques are those on life-support systems, with
cardiac pacemakers, and with intracranial aneurysm
clips.
885
igure 1A — A transaxial section through the centrum semi
i vale demonstrating a rather typical demyelinating disease
rocess pattern with multiple areas of increased NMR signal
i the periventricular areas and central white matter (open
> rrows).
Figure IB — A midsagittal image demonstrating considerable
'cortical atrophy (open arrows) as well as clear delineation of
[ he fourth ventricle (black arrowhead) as well as exquisite
[delineation of the normal aqueduct (small black arrow).
|i>f the head and body recognizing this technique as a
safe and effective medical advance. Patient cooperation
|and acceptance of the procedure have been excellent.
DISCUSSION
MRI appears to be superior to CT in evaluating most
ibnormalities of the nervous system. The technique
|/OL. 81— NUMBER 10— OCTOBER 1984
Figure 3A — A transaxial image through the orbits, midbrain,
and temporal lobes and demonstrates the presence of mul-
tiple serpiginous low NMR signals seen in the left temporal
lobe (black arrows). Again, the orbits, lens, medial, and lateral
rectus muscles and optic nerves are seen.
Figure 3B — A coronal view demonstrates the temporal lobe
location of this angiographically documented arteriovenous
malformation.
In contrast to x-ray computed tomography (CT),
which relies on x-ray attenuation, MR images reflect
the interaction of hydrogen protons with strong gra-
dient magnetic fields and radiofrequency pulses. The
proper selection of imaging sequences is challenging
to the radiologist who must weigh signal to noise
ratios, contrast and spatial resolution, imaging times,
and imaging planes.
Marked improvement in the contrast resolution and
Figure 4A — This illustrates marked cerebellar hypoplasi
Both cerebellar hemispheres (open arrows) are hypoplasti
an enlarged cistema magna is noted. The basilar artery (smc
black arrow) is clearly demonstrated. The maxillary sinusr
and retroantral fat are clearly depicted.
Figure 4B — An enlarged fourth ventricle (black arrowhead) a
well as marked degree of cerebellar hvpoplasia (open arrow
The interpeduncular and prepontine cisterns also ar
enlarged and the spinal cord is somewhat atrophic.
soft tissue discrimination are only two of the striking
advantages of MRI. Several other factors herald an ex
citing future. MR images are totally noninvasive an
do not require the injection of iodinated contrast
agents. The patient receives no exposure to ionizing
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE'
886
, ricular enlargement (black arrowheads) with the presence ol
, 1 high NMR signal area in the anterior superior aspect (black
arrows) of the third ventricle typical in location for a colloid
I Figure 5B — A second echo midsagittal section illustrating the
oresence of the high NMR signal in the anterior superior
aspect of the third ventricle (black arrow) typical in location
(for a colloid cyst. The anterior cerebral artery is seen as is
‘ (the basilar artery.
radiation and there are no known biological haz-
ards.1011 Projections are readily obtained directly in any
ii .plane and the image degradation commonly seen in CT
' reconstruction of sagittal images does not occur with
i( MRI. The ability to visualize directly in coronal, sagit-
s jtal, and axial planes, and the remarkable ease with
. which this can be accomplished, allows for greater
Figure 6 — Periventricular edema (open arrows) surrounding
mildly dilated lateral ventricles.
precision in anatomic location. Bone artifacts are
absent in MRI. This allows for clear visualization of
many structures, e.g. posterior fossa brain stem,
spinal cord, which are less well seen by CT. Blood ves-
sels are extremely well seen without the need for in-
travenous contrast material.1213
It clearly has been documented that MRI is vastly
superior to CT in the diagnosis of white matter dis-
eases of brain14 including multiple sclerosis, leukodys-
trophy, and Biswanger's disease. MRI is equal to or
superior to CT in most intracranial pathological con-
ditions.15 In a series of 70 cases, MRI detected an ab-
normality missed with CT or showed more lesions
than did CT in 16 patients16 including metastatic dis-
ease, postinfectious states, and posterior fossa and
brain stem pathology. Recently, reports of the useful-
ness of MRI in the diagnosis of head trauma including
isodense subdural hematoma has been described.1718
Lesions of the spinal cord including syringomyelia and
cord tumors are ideally visualized by MRI as well. Be-
cause MRI is free of biological hazards and is totally
noninvasive, its usefulness as a screening procedure
is unrivaled. In addition, its superb contrast resolution
enables MRI to be an extremely sensitive diagnostic
modality in imaging the brain and central nervous
system.
REFERENCES
1. Lautebur PC: Image formation by induced local inter-
actions: Examples employing nuclear magnetic resonance.
Nature 242:190-191, 1973.
2. Hrieak H, Williams RD, Spring DB, et til.: Anatomy and
pathology of the male pelvis by magnetic resonance imaging.
AJR 141:1 101-11 10, 1983.
3. Hrieak H, Alpers C, Crooks LE. Sheldon PE: Magnetic
resonance imaging of the female pelvis. AJR 141:1 1 19-1 128,
1983.
4. Smith FW, Mallard JR, Reed A, Hutchinson JMS: Nuclear
magnetic resonance tomographic imaging in liver disease.
Lancet 1:963-966, 1981.
E VOL. 81— NUMBER 10— OCTOBER 1984
887
6
Figure 7 A — A transaxial view reveals the presence of a large
area of increased NMR signal (small black arrows), the central
portion of which reveals an area of some decreased NMR
signal (open arrow). The lower NMR signal area corresponds
to the actual neoplasm (glioblastoma) while the higher NMR
signal corresponds to extensive surrounding cerebral edema
Enlarged frontal sinuses and periventricular edema also is
noted.
5. Lanzer P, Botvinick EH, Schiller NB, et al.: Cardiac imag-
ing using gated magnetic resonance. Radiology 1 50: 121 1 27,
1984.
6. Smith FW, Reid A, Hutchinson JMS, Mallard JR Nuclear
magnetic resonance imaging of the pancreas. Radiology
142:677-680, 1982.
7. Hricak H, Crooks LE, Sheldon PE, Kaufman L: Nuclear
magnetic resonance imaging of the kidney. Radiology
146:425-432, 1983.
8. Moon KL, Hricak H, Crooks LE, et al.: Nuclear magnetic
resonance imaging of the adrenal gland: A preliminary report.
Radiology 147:155-160, 1983.
9. Moon KL, Genant HK, Helms CA, et al.: Musculoskeletal
applications of nuclear magnetic resonance. Radiology
147:161 171, 1983.
10. Wolff S, Crooks LE, Brown P, et al.: Tests for DNA and
chromosomal damage induced by nuclear magnetic reso-
nance imaging. Radiology 136:707-710, 1980.
11. Schwartz JL, Crooks LE: NMR imaging produces no
Figure 7B — A parasagittal view demonstrates the infiltrate
high NMR signal seen as a result of this malignant tur'fi
(small black arrows) and again the area of decreased Nit
signal corresponds to the area of actual neoplasia.
observable mutation or cytotoxicity in mammalion cells. A?l ,
180:707-710, 1980.
12. Kaufman L, Crooks LE, Sheldon PE, et al.: Evaluatiu .
of NMR imaging for detection and quantification of obstn '
tion in vessels. Invest Radiol 17:554-560. 1982.
13. Alfidi J, Haaga JR El Yousef SJ, et al.: Preliminr
experimental results in humans and animals with a sup-
conducting, whole body nuclear magnetic resonance scann ..
Radiology 1 43: 1 75 181, 1982.
14. Young IR Randell CP, Kaplan PW, et al.: Nuclei
magnetic resonance imaging in white matter diseases of t J
brain using spin-echo sequences. J Comput Assist Tomi’I
7:290-294, 1983.
15. Byddar GM, Steiner RE, Young IR et al.: Clinical Nl\|
imaging of the brain: 140 cases. AJR 319:215-236, 1982 |
16. Brant Zawadzki M, Davis PL, Crooks LE, et al.: NY:
demonstration of cerebral abnormalities: Comparison will
CT. AJR 140:847-854, 1983.
1 7. Han JS, Kaufman B, Alfidi RJ, et al.: Head trauma eva >1
ated by magnetic resonance and computed tomography:.!
comparison. Radiology 150:71-77, 1984.
18. Sipponen JT, Sipponen RE, Sivula A- Chronic subdu 1
hematoma: Demonstration by magnetic resonance. Rad |
logy 150:79-85, 1984.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
888
Update: Immunizations
During Pregnancy
Stephen R. Preblud, m.d., Kenneth J. Bart, m.d., Alan R. Hinman, m.d., Atlanta, ga*
»
In this essay , the authors clarify the Centers for Disease
Control recommendations regarding rubella vaccination of
postpubertal females.
This essay is in response to the
article, “Guidelines for Im-
munization During Pregnancy,”
>y Dreyfuss et al. in The Journal in July 1983. On page
>12, it is stated: "The CDC currently recommends that
ubella vaccine be administered only after pregnancy
las been ruled out. . . .” While it has been some time
ince the article appeared, we think it is important to
larify the CDC recommendations regarding vacci-
nation of postpubertal females.
The authors imply that some sort of test be per-
ormed to rule out pregnancy. However, as of 1978 the
mmunization Practices Advisory Committee (ACIP) of
he CDC has recommended: “In view of the importance
>f protecting this age group against rubella, asking
emales if they are pregnant, excluding those who are,
ind explaining the theoretical risks to the others are
easonable precautions in a rubella immunization pro-
gram.” Neither pregnancy testing nor prevaccination
serologic screening routinely are recommended. These
ecommendations have been repeated in the ACIP
statements that appeared subsequently,1 the most re-
sent being in the June 8, 1984, issue of the MMWR.2
The authors express concern about the teratogenic
potential of the RA 27/3 vaccine licensed in the United
States in 1979. Information published at the time that
he article appeared in The Journal, but that was not
sited, indicated that the RA 27/3 vaccine had no more
eratogenic potential than the other previously avail-
vOL. 81— NUMBER 10— OCTOBER 1984
able rubella vaccines.3 5 As of December 1 983 no CRS-
like defects have been observed in 121 infants bom to
susceptible women who received the RA 27/3 vaccine
within 3 months before or after the estimated date of
conception.6 Thus, the data continue to show that the
fetal risk associated with the RA 27/3 vaccine “is so
small as to be negligible and ordinarily should not be
a reason to consider interruption of pregnancy.”2 Be-
cause of the theoretical risk of fetal defects, the vaccine
still should not be given to women known to be preg-
nant.
Vaccination of children has resulted in a dramatic
decrease in the reported incidence rates of rubella and
congenital rubella syndrome (CRS) in this countiy.7
The provisional 1983 totals for rubella (954 cases) and
CRS (4 cases that are confirmed or compatible with
the syndrome) represent alltime lows.89 As vaccinated
children enter the childbearing age, rubella and CRS
will be eliminated. However, this process will take 10
to 30 years. In the meantime, a relatively small but
preventable number of CRS cases will continue to
occur, each with an estimated lifetime cost in excess
‘From the Department of Health and Human Services,
Centers for Disease Control, Atlanta, Georgia, where Dr.
Preblud is Medical Epidemiologist, Dr. Bart is Chief,
Surveillance, Investigations and Research Branch, and Dr.
Hinman is Director, Division of Immunization, Center for
Prevention Services.
889
.'00 000. 10 The continuing occurrence of rubella in
childbearing age populations is a result of a failure
either to have been infected or vaccinated. Approx-
imately 10 to 15 percent of this population still is
susceptible, a rate similar to that noted in prevaccine
years.7
The elimination of CRS can be hastened by increas-
ing our efforts to effectively vaccinate postpubertal in-
dividuals, especially women. Such efforts recently have
resulted in a decline in the reported incidence rate of
rubella in postpubertal persons.89 An important ele-
ment in this progress has been vaccinating this popu-
lation according to ACIP guidelines for determining
immunity, i.e. having written proof of vaccination on
or after the first birthday or documentation of positive
serologic testing.2 Vaccine is indicated for all individ-
uals lacking either of these two criteria of immunity
(a physician’s diagnosis of rubella is unreliable and is
not acceptable for proof of immunity).
Great strides have been made in the control and
eventual elimination of CRS. It is important to clarity
for the readership what the current rubella vacci-
nation recommendations are so vaccine may be given
effectively to those most in need.
REFERENCES
1. Immunization Practices Advisory Committee: Rubeii
prevention. MMWR 30:37-42, 47, 1981.
2. Immunization Practices Advisory Committee: Rubeii
prevention. MMWR 33:301-10, 315-318, 1984.
3. Preblud SR Stetler HC, Frank JA Jr, Greaves WL, Hi
man AR Herrmann KL: Fetal risk associated with rube,
vaccine. JAMA 246:1413-7, 1417, 1981.
4. Centers for Disease Control: Rubella vaccination durir
pregnancy — United States, 1971-1981. MMWR 31:477-4£
1982.
5. Centers for Disease Control: Rubella vaccination durii;
pregnancy — United States, 1971-1982. MMWR 32:429-4o
1983.
6. Centers for Disease Control: Rubella vaccination durii i
pregnancy — United States, 1971-1983. MMWR 33:365-3£
373, 1984.
7. Orenstein WA Bart KJ, Hinman AR et al.: The o
portunity and obligation to eliminate rubella from the Unit .
States. JAMA 251:1988, 1984.
8. Centers for Disease Control: Rubella and congenil
rubella— United States, 1980-1983. MMWR 32:505-510, 19£
9. Centers for Disease Control: Rubella and congenil (
rubella— United States, 1983. MMWR 33:237-242, 247, 198
1 0. Koplan JP, White CC: An update of the benefits and cc >
of measles and rubella immunization, in, proceedings of t;
symposium, “Conquest of Agents that Endanger the BrairH
Baltimore, MD, October 28-29, 1982 (in press).
|
890
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
COMMENTARY: UPDATE OF
Diagnostic Related Groups
1
Martin E. Johnson, lawrenceville*
Under the Diagnosis Related Group (DRG) system , New Jersey
hospitals are reimbursed on a fixed rate . DRGs have not proved
their effectiveness or value. An evaluation of the system is needed.
The year 1979 ushered in a
change in health care delivery
for 20 hospitals in the state of
Jew Jersey. It was the year the Yale School of Public
lealth’s program of Diagnostic Related Groups (DRGs)
ystem of payment for hospital care was to be given
i field trial. The New Jersey Department of Health
ought and received a $2 million federal grant in 1976
o fund an “experimental” application of the DRG con-
ept. While the experiment never was completed as an
•bjeetive study, the state’s 104 general hospitals went
n the DRG system in three groups between 1 980 and
982.
Under the DRG system, the hospitals no longer are
eimbursed for what was spent to treat the patient,
'he payment is based on a fixed rate for each of the
-67 categories of DRGs. Under this system, hospitals
3se money if they spend more than the assigned rate
nd they keep the difference if they spend less than
he assigned rate. This gives hospitals a financial in-
entive to be selective and cost conscious; but it does
iot assure optimal care and it could prejudice the
reatment selected.
Early legislative activity coupled with unwarranted
egulatoiy zeal brought about a statewide adoption of
he DRGs without a definitive evaluation.
A former Commissioner of Health, who was a prime
nover for the DRG system in New Jersey, with the use
f some unusual mental gymnastics indicated it was
“neither appropriate nor possible to evaluate the DRG
system until all the hospitals have been on it for a full
year.” This philosophy flies in the face of all accepted
procedures for orderly evaluation of a delivery system
prior to full implementaton. To do so, the Department
of Health applied for and received a five-year, $4 million
federal grant to continue the experiment. The program
still is to be given a valid evaluation even though it was
introduced statewide in 1980.
The current Commissioner of Health, Dr. J. Richard
Goldstein, has stated “The hospitals are responding to
the DRGs cost-cutting incentives and patient care has
not suffered.” The credibility of this statement was
challenged by Dr. Goldstein when he said that there
is “no single measure of whether the system is work-
ing.” He further stated the national rate of change in
hospital operating expenses is the state’s “yardstick
for comparison” and that “we would like to do better
than the national average”— something New Jersey
was doing prior to the implementation of DRGs.
As mentioned in a commentary on DRGs that ap-
peared in the May 1984 issue of The Journal of the
Medical Society of New Jersey, Mr. Vincent Maressa
Executive Director of the Medical Society, indicated
the rate of hospital care costs in New Jersey for six
"Mr. Johnson is Director of Public Affairs and Medical Educa-
tion, MSNJ. Correspondence may be addressed to Mr. John
son, MSNJ, Two Princess Road, Lawrenceville. NJ 08648.
OL. 81— NUMBER 10— OCTOBER 1984
891
prior to the DRGs installation in New Jersey. The
Hew Jersey hospitals averaged 3.5 percent below the
national average. The first year after the program was
used. New Jersey came in 3.4 percent below the na-
tional average; the second year New Jersey came in 4.7
percent below the national average. On the surface,
this would look encouraging until you consider the
fact that the national average of cost increase for that
year was 1.7 percent more than the established trend
had been.
The Department of Health stated that the first year
of DRGs net patient service revenue increased 22.6
percent. The actual costs increased 13.6 percent. This
reflects in a 36 percent or more increase in cost to the
public. The second year, the net revenues increased by
14.8 percent and the costs went up 14.0 percent for
a cost increase to the patient of 28.8 percent or more.
It is unlikely that state and national bureaucrats will
admit the error of their ways. Under such a situation
it is inevitable that the DRG system will collapse. They
will in all probability try to implicate the medical pro-
fession in the disaster to shift the blame from its right-
ful place.
There have been several articles in The New York
Times of recent date that have pointed out the dif-
ferences of opinion regarding the value of DRGs and
its effect on hospital care. One of the articles,
"Statistical Analysis Difficult,” indicated the complexi-
ty of the New Jersey DRG system has created problems
for those charged with running the program as well
as those evaluating it. The difficulty in arriving at a
viable statistical analysis was referred to by Dr. William
Hsio, a Harvard University School of Public Healt
economist. He indicated “a lot of effort went into in
plementing the DRG program, but, not enough plar
ning was done in how to evaluate the results.” Th
same article quoted Stanford Weiner, a political scier
tist from M.I.T., as stating “It is striking that a prograi
now entering its fifth year, a program that involves $
billion in hospital reimbursements, that nothing clos
to reliable numbers are available from either the stal
or the federal government.”
Dr. J. Richard Goldstein, Commissioner of Health, i
the same article acknowledged that more attentio
was given to how to implement the DRG program tha
how to evaluate it. He stated, “This was typical of mo: ■
government-sponsored programs.”
Dr. Frank J. Primich in a letter to the editor of Th
New York Times referred to the April 2, 1984, editoria ;
“Failure of a Hospital Diet.” Dr. Primich indicated th;
government, labor and management, and insuranc
industry have promised more than they can provid
Recently, the Health Care Financing Administratioll
advised the Department of Health that the New Jerse
DRG waiver is revoked, effective December 31, 198<
What was bom in confusion and raised in haste hi
grown into a runaway monster without responsibilil
or control.
Free enterprise does not mean “free lunch.” Pn
gramming of restrictive hospital health care withor
a system of accountability that encompasses a ;
aspects of the delivery of that care is sheer lunacy an
typical of bureaucratic bungling. It is fraught wit
danger and doomed to failure.
892
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
>OCTORS*
fOTEBOOK
Trustees' Minutes;
UMDNJ Notes; MSNJ
Auxiliary; New Members;
Tamisiea Award;
Physicians Seeking
Location in New Jersey
trustees’ Minutes
illy 15, 1984
A regular meeting of the Board of
mstees was held on Sunday, July
3, 1984, at the Executive Offices in
twrenceville. Detailed minutes are
a file with the secretary of your
>unty society. A summary of sig-
ficant actions follows:
eport of the President . . .
) State Board of Medical Exam-
ers’ Meeting on Chiropractic . . .
4ted that a proposal expanding the
andards and scope of chiropractic
as referred back to the State Board
pmmittee on Chiropractic for a de-
rmination on appropriate tests to
b performed by chiropractors.
0 Annual Meeting Scientific
sssion Format . . . Noted a sugges-
jbn that scientific sessions at the
nnual Meeting concentrate on only
ie topic.
eport of the Executive
irector . . .
) MSNJ 1984 Membership . . .
bted that as of June 30, 1984,
embership was at 7,299. Noted the
bssibility of including a request for
payment of first-year dues with the
membership application.
(2) MSNJ Financial State-
ments . . . Approved the unaudited
financial statements for the period
ending May 31, 1984.
(3) Legal Matters . . .
(a) SBME v Greco . . . Authorized
MSNJ to join in the petition for
certification in the Greco case.
(b) Federal Trade Commission . . .
Noted a preliminary response has
been filed with the Federal Trade
Commission in response to their in-
vestigation of MSNJ, relating to the
potential violation of price fixing
and market restraint.
(c) Subordinated Loan Status . . .
Noted final decision on sub-
ordinated loan litigation still is
pending in Tax Court.
(4) Medicaid . . . Noted that a sub-
committee of the Medicaid Cost
Containment Committee has rec-
ommended that physicians’ fees for
ambulatory and office care be up-
graded in accordance with the plan
designed for Atlantic and Mercer
counties; the subcommittee also has
recommended reapplication to the
federal government to institute the
project.
(5) Medicare Fee Freeze . . .
Agreed that the AMA should be re-
quested to review the Medicare fee
freeze carefully, and give consider-
ation to the litigation of all ap-
propriate issues on behalf of all U.S.
physicians.
(6) Physician Supervision of Lim-
ited Licensed Practitioners . . . Ad-
vised that a response from MSNJ
will be released shortly on the matter
of physician supervision of limited
licensed practitioners.
(7) Membership Directory
Voted to continue listing the names
of all physicians in the hospital staff
section.
NJ Hospital Association . . .
(1) DRG Waiver . . . Received as in-
formative a report concerning the
application guidelines on the dem-
onstration waiver which permits
Medicare to participate in the DRG
program.
Note: Due to increasing hospital
rates, the demonstration waiver is
revoked and New Jersey must obtain
a new waiver or note that hospitals
will be paid for Medicare services in
accordance with the national pro-
spective payment system beginning
January 1, 1985.
Medical Society of New Jersey
Student Association . . . Endorsed
the resolution submitted by the Stu-
dent Association to request the
Board of Trustees of UMDNJ not to
change the nomenclature of UMDNJ
component schools.
Council on Public Relations . . .
(1) Patient Education Pro-
gram-Resolution #15 (1984) . . .
Approved the following three rec-
ommendations:
(1) That there not be a voluntary
assessment of the membership at this
time.
(2) That $40,000 be reallocated from
various other accounts to public rela-
tions for the 1984 to 1985 fiscal year,
bringing the public relations account to
$160,000.
(3) That a minimum amount of
$200,000 to $225,000 be put into the
1985 to 1986 budget for public relations
purposes.
(2) MSNJ Public Relations
Firm . . . Approved the following rec-
ommendation:
That the Medical Society of New Jersey
retain the present public relations firm
for the current year. Several public rela-
tions firms will be interviewed and re-
quested to provide proposals adapted to
a future budget of $200,000-$225,000.
Committee on Impaired
Physicians . . .
(1) Protocol for the Management
of Physicians Alleged To Be Neu-
* ©logically Impaired or Senile and
No Longer Competent Practition-
ers . . . Approved the following rec-
ommendation:
That the Board of Trustees endorse the
Protocol for the Management of Phy-
sicians Alleged To Be Neurologically Im-
paired or Senile and No Longer Compe-
tent Practitioners.
(2) Protocol for the Management
of Physicians Accused of Sexual
Misconduct . . . Approved the fol-
lowing recommendation:
That the Board of Trustees endorse the
Protocol for the Management of Physi-
cians Accused of Sexual Misconduct.
(3) License Applications Form . . .
Approved the following resolution:
That the resolution in support of the
position of the New Jersey Psychiatric
Association regarding the present New
Jersey Medical Application form be en-
dorsed.
3L. 81— NUMBER 10— OCTOBER 1984
893
(4) AMA Conference on Impaired
Physicians . . . Approved the follow-
ing recommendation:
That MSNJ will underwrite, from the
Impaired Physicians Program budget,
the expenses incurred by Dr. Ivovich, Dr.
McBride, and Edward Reading while at-
tending the AMA meeting on the Im-
paired Physician in September at the
Meadowlands Hilton in Secaucus.
Committee on Conservation of
Vision . . . Approved the following
recommendation concerning the
Statewide Eye Screening Coordi-
nating Council:
That the Medical Society of New Jersey
endorse the formation of a Statewide Eye
Screening Coordinating Council by the
New Jersey State Commission for the
Blind and Visually Impaired and appoint
a representative from the Committee on
Conservation of Vision to serve on the
Council.
Old Business . . .
( 1 ) Health Care Facilities Planning
Act — Certificate of Need . . . Noted
that MSNJ’s position remains the
same concerning the Health Care
Facilities Planning Act: MSNJ would
support an amendment requiring a
certificate of need from all sources
on services that have been re-
gionalized via a duly adopted regu-
lation, contingent upon the re-
gionalization regulation automati-
cally expiring after two years unless
readopted on the basis of demon-
strated need.
(2) Physicians’ Assistants . . .
Noted that MSNJ is opposed to the
concept of licensure of physicians’
assistants in New Jersey.
IJMDNJ Notes
Stanley S. Bergen, Jr., M.D.
UMDNJ’s ability to care for pa-
tients and to provide specialized ser-
vices for some of the more difficult
cases of physicians practicing in
New Jersey will be enhanced greatly
if the 8241 million budget for 1985
to 1986 adopted by our Board of
Trustees makes it through the long
state appropriation process without
damaging cuts.
Among budgeted plans for de-
velopment of clinical specialty pro-
grams are 8 1.6 million for faculty
and enhancement of radiation ther-
apy, chemotherapy, and pathology
programs at the Cancer Research
and Treatment Center on the New-
ark campus: 84 million for a new
cardiac surgery unit at University
Hospital in Newark and additional
clinical faculty at both UMDNJ-
Rutgers Medical School, Piscata-
way/New Brunswick and UMDNJ-
New Jersey Medical School, Newark;
and 81 million for expanding the re-
gional trauma centers at Cooper
Hospital/University Medical Center,
Camden, and University Hospital,
Newark.
Hospital revenues would account
for most of the 83 million increase
planned to improve the neuro-
surgery program at University Hos-
pital and staff-donated nuclear
magnetic resonance (NMR) imaging
equipment at University Hospital,
expand pulmonary, anesthesiology,
and immunology subspecialties at
the medical school; and open new
educational programs in southern
New Jersey.
Our budget proposal is ambitious
but responsible, focusing on Univer-
sity-wide priorities that are based on
their importance to New Jersey’s
health care needs and UMDNJ's
long-term goals.
In light of the high rate of cancer
mortality in New Jersey, there is sig-
nificant activity by the state's public
university of the health sciences to
combat this disease through the
most effective therapies known, by
educating cancer specialists, and in
continuing research to find causes
and cures. These developments on
the cancer front are noteworthy:
• The Newark-based Cancer Re-
search and Treatment Center, part
of University Hospital, has opened a
“cancer hotline” available to phy-
sicians wanting to make direct refer-
rals and to students doing research.
The number, (1-201) 456-6666, is
served by a Cancer Center employee
during business hours and an
answering service on nights and
weekends.
• The cancer program at Univer-
sity Hospital has received a three-
year certificate of approval from the
Commission on Cancer of the
American College of Physicians. The
approval designated the Newark pro-
gram at the “teaching hospital” level.
® Twelve UMDNJ faculty members
were awarded more than 8876,000
of the first 81.2 million granted by
the state’s new Commission on
Cancer Research to undertake basic
research that will enlarge our knowl-
edge of this disease. The new sta
program, funded by a five-cent i
on cigarettes, is providing vital s*d
money for promising laboratory j
search efforts that may gener e
added support from other souru
One faculty member, Chung S. Yaj,
Ph.D., professor of biochemistry);
UMDNJ-New Jersey Medical Schd.
has received a state grant of 880,(0
to study the link betwen
esophageal cancer and the si-
ergestic effects of alcohol consun
tion and smoking, and has n
American Cancer Society grant)!
8155,987 to investigate the conr:-
tion between esophageal cancer ag
riboflavin deficiency.
It is a great pleasure for me to i
nounce the appointment of Dr. Ri :
ard C. Reynolds as UMDNJ’s fi!it
senior vice-president for acadeijj
affairs.
We are fortunate to have an ir
vidual of Dean Reynold’s
complishment and recognized
pertise to provide the administral
leadership on academic progras
and policies for the University. In
absence, he will assume
authority and responsibilities of
president of UMDNJ.
Dr. Reynolds, an internist
e
£0
community health specialist, ca
to UMDNJ in 1978 by way of
Johns Hopkins University Schoo
Medicine and University of Flor
School of Medicine.
His leadership of the UMDlifj
Rutgers Medical School througla;
complicated and difficult periodjifl
growth is testament to his leacji
ship abilities and calm, consider e
personality; he continues as dear!
that school.
The first Distinguished Profes r
title to be awarded by the UMDJ)
Board of Trustees has been giver o
R. Walter Schlesinger, M...
emeritus professor of microbiol<y
at UMDNJ-Rutgers Medical Sch>l
and a world-renowned virologist, rj
Schlesinger came to UMDNJ in 191
as professor and chairman of the -
partment of microbiology, served s
assistant dean of UMDNJ-Rutgs
Medical School from 1963 to 191
and acting dean in 1970 to 1971. e
has received a number of outstaj -
ing awards, published extensivfj
and been active in a variety of scfj -
tific organizations and projects, e
continues researching the n -
tionship of influenza to neurologitl
complications.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
894
tlSNJ Auxiliary
irace Ge liman
>resident
Thank you Auxiliary members for
olunteering your time and talents
oward the statewide “Eye Health
Screening Program" held during the
/eek of September 17, 1984.
A note of appreciation to Mrs.
Charles Moloney and her committee
3r arranging the super workshop
n September 24, 1984, in Law-
enceville. The workshop, “Avenues
eading to Personal Success,” was
resented by John J. Moore, Ph.D., of
oyola University, Chicago. It was a
are opportunity for the member-
hip to enhance those qualities of
leadership they already demon-
trate.
Are you registered to vote? Is your
pouse registered to vote? Do not sit
his election out. Do it together —
ote on November 6, 1984.
We are fortunate to have an Aux-
iary member who also is a travel
gent. She can write all travel ar-
angements— airline tickets and
otel accommodations— and has
greed to contribute her share of
commission from these arrange-
ments directly to the Medical Stu-
dent Loan Fund in the name of the
respective county. Call Mrs. John
Holdcraft (Grace) at (1-609)
848-2788 for further information.
New Members
The Journal of the Medical So-
ciety of New Jersey would like to wel-
come the following new members:
Atlantic County
Wilfredo Carreno, M.D., Linwood
Frederick G. Dalzell, M.D., Northfield
James A Wilson, M.D., West Orange
Bergen County
Fe S. Arboleda, M.D., Dumont
Deodatta V. Bendre, M.D., Ridgewood
Richard A. D’Amico, M.D., Englewood
Russell A Ferstandig, M.D., Ridgewood
John D. Frattarola, M.D., Fort Lee
Salvatore Infantino, M.D., Fair Lawn
David N. Levin, M.D., Teaneek
Norma Jean Murray, M.D., Cliffside Park
George A. Remisovsky, M.D., Fort Lee
Steven M. Stoller, M.D., Ridgewood
Bruce N. Terrin, M.D., Hackensack
Burlington County
Ivan T. Krohn, M.D., Moorestown
J. Mark J. Meredith, M.D., Vincentown
Jeffrey B. Morris, M.D., Marlton
Mark A Tatz, M.D., Mount Laurel
Camden County
Nathan I. Feldman, M.D., Voorhees
Richard M. Goldfarb, M.D., Voorhees
Robert B. Hill, M.D., Camden
Leonard I. Japko, M.D., Camden
George R Kenner, Jr., M.D., Camden
Sidi Y. Noor, M.D., Voorhees
Michael J. Reichman, M.D., Cherry Hill
Kenneth J. Weiss, M.D., Camden
Cape May County
Wai-Ling Lai, M.D., Cape May Court
House
Cumberland County
Robert E. Coifman, M.D., Vineland
Howard Leibowitz, M.D., Vineland
Armando P. Russo, M.D., Vineland
Rajendra M.R Sharma, M.D., Vineland
Dirk E. Skinner, M.D., Vineland
Essex County
Carol A Bainbridge, M.D., Bloomfield
Herbert L. Glatt, M.D., Bloomfield
Stanley Klughaupt, M.D., Belleville
Nicholas G. Melillo, M.D., West Orange
Dragan Pecirep, M.D., Newark
Louis J. Petracca, M.D., Bloomfield
Alan J. Sarokhan, M.D., Short Hills
Ajit M. Shah, M.D., Caldwell
Hilda B. Templeton, M.D., West Orange
Gloucester County
Jeffrey T. Gibson, M.D., Woodbury
James C. McMaster, D.O., Woodbury
Laurence A Primack, M.D., Sewall
Hudson County
Edith E. Andrade, M.D., North Bergen
Angelo DeMarco, M.D., Newark
Stephen P. McCarthy, M.D., Bayonne
Hunterdon County
Jan K. Kniskem, M.D., Flemington
The Journal of the Medical Society of New Jersey
announces the reprinting of the
WILLIAM CARLOS WILLIAMS
COMMEMORATIVE ISSUE
September, 1983
Honoring the 100th anniversary of the birth of New Jersey’s prize-winning poet and physician.
Included in this handsomely illustrated, full-color issue will be original articles by persons
close to William Carlos Williams, artwork from his social and intellectual circle, and samples
of his finest writings.
Copies of this special issue are available by sending $5.00 for each (check or money order)
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648.
Please send a copy of the William Carlos Williams Commemorative Issue to:
—
Enclose a $5.00 check or money order for each copy.
OL. 81— NUMBER 10— OCTOBER 1980 895
Mercer County
KanizaA. Banglawala M.D.,
Lawrenceville
Alexanders. Carney, M.D., Princeton
Prabodhkumar Damani, M.D., Trenton
Charles J.F. McHugh, M.D., Voorhees
John J. Shelmet, M.D., Trenton
Venkateswaraiyer Subramoni, M.D.,
Hamilton
Eugene U. Thiessen, M.D., Hightstown
Middlesex County
Venis F. Fanous. M.D., South Bound
Brook
Geeta R Ghanekar, M.D., Iselin
Dieter M. Kramsch, M.D., Rahway
Gary H. Levin, M.D., Edison
Soheir Saad El-Dine Ramadan, M.D.,
Morristown
Luz E. Rodriquez, M.D., Metuchen
Krishnaswami Srinivasan. M.D., Parlin
Craig J. Wiederman, M .D.. Woodbridge
Monmouth County
Steven Berkowitz, M.D., Neptune City
Michael Lee Bernstein, M.D., Colts Neck
Steven A. Bohm, M.D., Freehold
Jeffrey M. Chalal, M.D., Marlboro
Paul M. DiLorenzo, M.D., Asbury Park
Anthony Emanuel, M.D., Freehold
Russell A. Gross, M.D., Colts Neck
Shelly L. Ludwig. M.D., Freehold
Norman S. Nolan, M.D., Middletown
Gerald E. Pflum, M.D., Shrewsbury
Diane Rose, M.D., Marlboro
Eric J. Rosenstock, M.D., Neptune
Vardha S. Sailam. M.D., Red Bank
Joseph W. Schauer, M.D., III, Farmingdale
Rajagopalan Sivaprasad, M.D., Long
Branch
Morris County
Eugenia George. M.D., Maplewood
Richard R Hawrylo. M.D., Morristown
ChongS. Jaw, M.D., Parsippany
Stephen D. Krasnica M.D., Denville
Bertram Kummel, M.D., Morristown
Barbara Mitchell, M.D., Morristown
Robert F. Mohr, M.D., Morristown
James B. Rubenstein, M.D.. Morristown
Ocean County
Bankim Shah, M.D.. Whiting
Passaic County
John J. Farkas, M.D., Paterson
Rita B. Jhaveri, M.D., Paterson
Thil Yoganathan, M.D., Paterson
Somerset County
Robert A. Harman. M.D., Somerville
Angela Lanfranchi. M.D., Bound Brook
Simon D. Murray, M.D., Somerset
Union County
Shalom Y. Abboudi, M.D., North
Plainfield
Kenneth M. Bahrt. M.D., Plainfield
Walter J. Borowski, M.D., Linden
John N. Burling, M.D.. Linden
Joseph P. Calderone, Jr., M.D.,
Mountainside
Thomas J. Gianis, M.D., Summit
James Scott Gillin, M.D., Summit
Alan W. Goldfeder, M.D., Union
Joseph Guida, M.D., Linden
Alan H. Greenspan, M.D., Westfield
Anthony Iuzzolino, M.D., Hillside
Sabata J. Lombardo, M.D., Elizabeth
Uday C. Mehta M.D., Mountainside
Bernard M. Wagner, M.D.. Summit
Tamisiea Award
At the annual meeting of the Aero-
space Medical Association, May 6 to
11, 1984, in San Diego, California,
Dr. Milton H. Gordon was the recipi-
ent of the John A. Tamisiea Award
given annually to an individual who
has made an outstanding contribu-
tion to the art and science of avia-
tion medicine in its application to
general aviation.
Dr. Gordon, a fellow of the Associa-
tion, moved to Israel with his wife,
Natalie, in 1974. Since that time he
has been serving as the civil air sur-
geon of the state of Israel, the chief
medical officer for civil aviation
medicine. In that capacity his
special field of interest has been
agricultural aviation and toxicology
in its relation to the health and safe-
ty of spray pilots and ground crews,
and it is for this particular area of
aviation medicine that he has been
especially recognized.
The Aerospace Medical Associa-
tion is the world’s largest society of
its kind with 4000 members con-
sisting of physicians, engineers,
physicists, physiologists, and air
crew members.
Dr. Gordon is a member of the
Medical Society of New Jersey.
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ALLERGY/IMMUNOLOGY— Leonard
Bielory, M.D., 688 Concerto La., Silver
Spring, MD 20901. UMDNJ 1980.
Board eligible. Solo preferred, but flex-
ible. Available March 1985.
T.M. Bokhari, M.D., 48 Anderson Pkwy.,
Cedar Grove, NJ 07009. FJMC. Also in-
fectious diseases (pediatric). Board
certified (PED). Group, partnership,
solo. Available.
ANESTHESIOLOGY— Cau Pham. M.D.,
856 Nelson, Apt. 206, Chicago, IL
60657. Saigon (South Vietnam) 1974.
Group or partnership. Available.
FAMILY MEDICINE— Maiy F. Cam-
pagnolo, M.D., 10 Overlook Rd., Apt. 5-
E, Summit, NJ 07901. George Wa-
ington University 1982. Board eligil *
Group or partnership. Available Jy
1985.
GASTROENTEROLOGY— Harry
Buraek, M.D., 5548 Waterman PI., ;
Louis, MO 63112. Albany 1978. A;
internal medicine. Board certifil.
Partnership, group, solo. Available.
Prakash V. Huded, M.D., 80-15 41 A.
Apt. 606, Elmhurst, NY 113 1
Kamatak (India) 1970. Board certifil.
Solo, group, partnership. Available.
Neil Tarkin, M.D., 6700 192nd
Fresh Meadows, NY 11365. New Yu
Medical 1978. Also, internal medich.
Board certified (IM). Any type pract
Available.
’IUbI
GENERAL MEDICINE— John J. Ki
M.D., 127 Garfield Ave., Jersey City, '
07305. Catholic Medical Coll™
(Korea) 1966. Group, partnership, so.
Available.
INTERNAL MEDICINE— David M. Brcjl
bart, M.D., 50 Hillpark Ave., Apt. k
Great Neck, NY 11021. SUNY-Dov
state 1979. Also pulmonary medici
Board certified (IM): board eligie
(PM). Pulmonary, pulmonary/ interld
medicine, multispeeialty group. Av
able July 1985.
Harry D. Buraek, M.D., 5548 Watemi
PI., St. Louis, MO 63112. Albany 19).
Also gastroenterology. Board certif i.
Partnership, group, solo. Available.
Aditi Gupta, M.D., 27 Sturbridge r.
West, Piscataway, NJ 08854. Ly
Hardinge (India) 1980. Board eligi ;.
Clinic/hospital or group. Available
Lee W. Hoffer, M.D., 1017 E. 80th ,
Brooklyn, NY 1 1236. Rome (Italy) 19).
Solo, partnership, group. Available
Quang T. Nguyen, M.D., 15 I.
Englewood Ave., Bergenfield, NJ 076.
Saigon (South Vietnam) 19'.
Subspecialty, nephrology. Bo;d
eligible. Any type practice. Availab;
Claudia Anne Pollet, M.D., 612
Parkway Dr.. Baltimore. MD 212!.
Mount Sinai 1981. Board eligi.1.
Salaried position in emergency rod,
clinic, or urgent care center. Availa ;.
Paul V. Renda M.D., 3206 Myra j...
Apt. D, Durham, NC 27707. Mo it
Sinai 1981. Board eligible. Solo, groj).
clinic (preferably southern NJ). Av.l-
able.
Virod K. Shah. M.D., 345 Watkins lA,
Battle Creek, MI 49017. M.P. SH
(India) 1975. Board eligible. Any t e
practice. Available.
Neil Tarkin, M.D., 6700 192nd
Fresh Meadows, NY 11365. New Yjk
Medical 1978. Also, internal medici.1
Board certified (IM). Any type pract.1.
Available.
Robert L. Werner, D.O., 148 Resen r
Rd., Parsippany, NJ 07054. UMD f-
NJSOM 1981. Board eligible. Solo r
partnership. Available July 1985.
NEPHROLOGY— Quang T. Nguyen, M,.
15 W. Englewood Ave., Bergenfield, J
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
896
07621. Saigon (South Vietnam) 1967.
Also, internal medicine. Board eligible.
Any type practice. Available.
IBSTETRICS/GYNECOLOGY— Edwin
R Guzman. M.D., 1200 E. 98th St..
Brooklyn, NY 1 1236. New York Medical
1980. Board eligible. Group or partner-
ship. Available.
Atul S. Sheth, M.D., 2951 S. King Dr..
Chicago. IL60616. T.N. Medical College
(India) 1972. Specializing in infertility,
reproductive endocrinology. Board
eligible. Partnership, single multiple
group practice, academia Available.
►CCUPATIONAL MEDICINE— Errol
Emmet Vernon, M.D., 2018 Pickerton
Dr„ Deer Park, TX 77536. University of
the West Indies (Jamaica) 1978. Board
eligible. Group. Available.
ATHOLOGY— Steven P. Katz, M.D..
9634 S. Karlov Ave„ Oak Lawn, IL
60453. Nebraska 1972. Board certified
(PA and CLIN). Hospital or group. Avail-
able on one month's notice.
EDIATRICS— Charles H. Geneslaw,
M.D., 8372 Loveridge Ct., Richmond,
VA 23229. UMDNJ 1982. Partnership.
Available Julv 1985.
ULMONARY MEDICINE— David M
Breidbart, M.D.. 50 Hillpark Ave., Apt.
j l-R Great Neck, NY 11021. SUNY-
Downstate. Also, internal medicine.
Board eligible (PM); board certified
(IM). Pulmonary, pulmonary/intemal
medicine, multispecialty group. Avail-
able July 1985.
URGERY, GENERAL— Leonardo A.
Garduno, M.D., 2170 S. Goebbert Rd.,
Apt. 1-109, Arlington Heights, I L 60005.
University of the East (Philippines)
1968. Any type practice. Available.
Daniel M. Goldman, M.D., 3450 Wayne
Ave., Apt. 19-S, Bronx, NY 10467. Also,
vascular surgery. Board eligible. Part-
nership or single specialty group.
Available July 1985.
David A. Guthrie, M.D., 3130 Heath-
stead PL, Charlotte, NC 28210. West
Virginia 1978. Also, vascular surgery.
, Board eligible. Group or partnership.
Available July 1985.
Barry Jordan, M.D., 260 Garth Rd.,
Scarsdale, NY 10583. South Carolina
1977. Board eligible. Group, partner-
ship, solo. Available.
J. Bernard LeSage, M.D., P.O. Box 699,
Middlesboro, KY 40965. Montreal
(Canada) 1945. Board certified. Admin-
istrative medicine. Available.
>URGERY, VASCULAR— Daniel M.
Goldman, M.D., 3450 Wayne Ave., Apt.
19-S, Bronx, NY 10467. Also, general
surgery. Board eligible. Partnership or
single specialty group. Available July
1985.
David A Guthrie, M.D., 3130 Heath-
stead Pl„ Charlotte, NC 28210. West
Virginia 1978. Also, general surgery.
Board eligible. Group or partnership.
Available July 1985.
OL. 81— NUMBER 10— OCTOBER 1984
i
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort
standing
s
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN«/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg
in a special base ot prolonged
therapeutic effect.
OOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25mg
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500
LIPO-NICIN®/100 mg.
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
(broWJJI THE BROWN PHARMACEUTICAL CO„ INC.
2500 West Sixth Street, Los Angeles, California 90057 PDR
THE ACADEMY OF MEDICINE
OF NEW JERSEY
presents
a symposium on
HYPERTHERMIA FOR
CANCER
Saturday, October 13, 1984
8:30 a. m. -3:00 p.m.
at
MSNJ HEADQUARTERS, Lawrenceville, N.J.
This Symposium will present the most current scientific infor-
mation concerning the concomitant use of Hyperthermia in the
treatment of cancer of the body, including the brain.
PROGRAM CHAIRMAN:
Arthur Winter, M.D.
Attending Neurological Surgery
The Hospital Center at Orange
Saint Barnabas Medical Center,
Livingston
For further information, please contact:
6e^yo/. EXECUTIVE OFFICES
\ The Academy of Medicine of New Jersey
5 Two Princess Road
® Lawrenceville, NJ 08648
of New Jersey (609) 896-1717
The Academy of Medicine of New Jersey
Physicians for Social Responsibility,
Northern New Jersey Chapter
Department of Preventive Medicine and Community Health
UMDNJ— New Jersey Medical School
present
a symposium on
POTENTIAL HUMAN AND
ECOLOGIC DISASTERS
Saturday, October 20, 1984
9:00 a. m. -3:00 p.m.
at
Town & Campus Restaurant
West Orange, New Jersey
Those who attend this conference will gain an understanding of ttll
following:
The consequences of exposure to high level radiation with a partic:
lar emphasis on long term effects on birth defect and tumor incident i
The consequences of exposure to low level radiation (radium ar
uranium). Mechanism of exposure and health risk will be discusse:
The health effects of exposure to leakage from chemical toxic was
disposal sites and all the available studies that have been complete
will be reviewed and the requirements for additional study will t; <
analyzed.
For further information, please contact:
■Kl°\
of New Jersey
EXECUTIVE OFFICES
The Academy of Medicine of New Jers
Two Princess Road
Lawrenceville, NJ 08648
(609) 896-1717
LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
WEDNESDAY, NOVEMBER 7, 1984
SUDDEN DEATH
MODERATOR: JOEL MORGANROTH, M.D.
3:00 CASE PRESENTATION Pasquale M. Procacci, M.D.
3:30 THE ROLE OF ELECTROPHYSIOLOGIC STUDIES
IN THE MANAGEMENT OF PATIENTS WITH
VENTRIBULAR ARRHYTHMIAS Charles R. Webb, M.D.
4:00 IDENTIFICATION OF PATIENTS AT HIGH RISK
TO SUDDEN DEATH Scott R. Spieiman, M.D.
4:30 CAN WE SELECT DRUGS BASED ON ELECTROPHYSIOLOGIC
MECHANISMS AND PHARMACOLOGIC PRINCIPLES? Leonard N. Horowitz, M.D.
5:00 NEW ANTI ARRHYTHMIC AGENTS: USE AND LIMITATIONS
OF ENCAINIDE, FLECANIDE, AMIODARONE, ETHMOZIN
AND MEXILITINE Joel Morganroth, M.D.
LECTURE HALL “A” — 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
**WINE & CHEESE SERVED FOLLOWING CONFERENCE**
898
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
:ME Calendar
The following is a list of
continuing medical
education courses for the
next two months. Contact
the sponsoring
organization for further
information.
'his list is compiled through the coop-
ration of the Committee on Medical
ducation of the Medical Society of New
ersey, the Academy of Medicine of New
ersey, the New Jersey Chapter of the
unerican Academy of Family Phy-
icians, and the Office of Continuing
ledical Education of the UMDNJ. For
formation on accreditation, please
ontact the sponsoring organizadon(s).
Indicated by italics— last line of each
:em.
ANESTHESIOLOGY
ov.
0 Dinner Meeting
6-9 P.M.— Ramada Inn, Clark
(NJ State Society of
Anesthesiologists and AiMNJ)
ARDIOLOGY
ov.
7 Modem Concepts in
Echocardiography
9:30-1 1 AM. — Bergen Pines County
Hospital, Paramus
(Bergen Pines County Hospital
and AMNJ)
5 Cardiology: Newer Cardiac Drugs
2-3 P.M. — John E. Runnells
Hospital of Union County
(John E. Runnells Hospital and
AMNJ)
«c.
8 Streptokinase and Percutaneous
Transluminar Angioplasty
12 noon— St. Mary's Hospital,
Orange
(AMNJ)
0L. 81— NUMBER 10— OCTOBER 1984
MEDICINE
Nov.
1 Antibiotic Updates
9 AM.— Freehold Area Hospital
(AMNJ)
1 Immunoregulation: Basic
8 Concepts and Applications
15 4-6 P.M.— Institute for Medical
29 Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
2 AIDS
12 noon-1 P.M.— Freehold Area
Hospital
(AMNJ)
2 ND-YAC Laser in G.I.
16 The Physician as a Patient
30 Sanity in Today’s Beta-Blocker
Market
9 AM — Crean Hall, St. Francis
Medical Center, Trenton
(St Francis Medical Center)
6 Antibiotic Update
9- 1 0 AM. —Freehold Area Hospital
(AMNJ)
7 AIDS
1-2:30 P.M. —Christ Hospital, Jersey
City
(AMNJ)
7 Indications for Invasive Studies
12 noon— St. Mary’s Hospital,
Passaic
(AMNJ)
7 Medical Grand Rounds
14 12 noon- 1 P.M.— Rutgers Medical
21 School, Medical Education Bldg.,
28 New Brunswick
(UMDNJ and AMNJ)
7 Medicine Morbidity and Mortality
Conference
8-9 A.M. — Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
7 Common Dermatoses
1:30-2:30 P.M. —Essex County
Hospital Center, Cedar Grove
(AMNJ)
7 Endocrine Conferences
14 3:30-5 P.M. —Rotates between
21 Newark Beth Israel Medical Center,
28 University Hospital, United
Hospitals Medical Center, Newark,
and VA Medical Center, East
Orange
(Endocrinology Section, AMNJ)
12 A New Medical Entity— Mixed
Angina
7- 8:30 P.M. — Wallkill Valley General
Hospital
(Pfizer Laboratories and AiMNJ)
13 Topic To Be Announced
8- 1 0 P.M.— Schering Corp.,
Kenilworth
(NJ Dermatological Society and
AMNJ)
1 4 Early Diagnosis and Treatment of
Commonly Seen Office Problems
8:30 A.M. -5 P.M.— Medical Society of
NJ, Lawrenceville
(NJ Academy of Family
Physiciar^s and AMNJ)
14 Dermatologic Manifestations of
Life-Threatening Illness
1 -2:30 P.M. —Bldg. 93, VA Medical
Center, Lyons
(VA Medical Center and AMNJ)
1 5 Diagnosis and Management of
Anaerobic Infection
5- 7:30 P.M. — Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
1 5 Case Presentations
8-10 P.M. —The Mountainside
Hospital, Montclair
(NJ Gastroenterological Society
and AMNJ)
20 New Treatment Modes and
Implications for the Future in
Diabetes
12 noon— St. Maiy's Hospital,
Orange
(St Mary’s Hospital and AMNJ)
21 Dermatological Conferences
6- 9 P.M. —Rutgers Community
Health Plan, U.S. Hwy. 1 & Rt. 18,
New Brunswick
(UMDNJ and AMNJ)
21 Mitral Valve Prolapse
1-2 P.M. — West Hudson Hospital,
Kearny
(West Hudson Hospital and
AMNJ)
2 1 Antiviral Update
28 Modem Concepts and Etiology of
Diabetes Mellitus
9:30-1 1 AM. — Bergen Pines County
Hospital, Paramus
(Bergen Pines County Hospital
and AMNJ)
28 Dermatologic Manifestations of
Life-Threatening Illness
1-2:30 P.M.— VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
28 Controversies in Geriatrics
1-5 P.M.— Medical Society of NJ,
Lawrenceville
(AMNJ)
29 Laser Treatment of Massive GI
Hemorrhage
1 1 AM.- 12 noon — St. Joseph's
Hospital and Medical Center,
Paterson
(AMNJ)
Dec.
4 AIDS
9:00 AM — Holy Name Hospital,
Teaneek
(AMNJ)
5 AIDS
9:00 AM. —Warren Hospital,
Phillipsburg
(AMNJ)
5 Clinical Abstract Meeting
1-5 P.M. — The Manor, West Orange
(Oncology Society of NJ and
AMNJ)
5 Endocrine Conferences
12 3:30-5 P.M. —Rotates between
19 Newark Beth Israel Medical Center.
26 University Hospital, United
Hospitals Medical Center. Newark,
and VA Medical Center. East
Orange
(Endocrinology Section and
AMNJ)
5 Medical Grand Rounds
12 12 noon-1 P.M. — Rutgers Medical
899
Temple University Hospital
Department of Orthopedic Surgery is
pleased to announce the association of
Russell E. Windsor, MD within the prac-
tice of orthopedic surgery including
joint reconstruction and sports medi-
cine.
THE MEDICAL SOCIETY OF NEW JERSEY
PRESENTS
WOMEN PHYSICIANS
LEADERSHIP CONFERENCE
SATURDAY, OCTOBER 27, 1984
8:30 AM-3:00 PM
MEDICAL EDUCATION BUILDING
UMDNJ-RUTGERS
NEW BRUNSWICK, NEW JERSEY
LUNCH & RECEPTION
STUDENTS RESIDENTS PHYSICIANS
$5.00 $10.00 $25.00
Reservations— 1 -609-896-1 766
1985 CME CRUISE/CONFERENCES ON SELECTED
MEDICAL TOPICS
Caribbean, Mexican, Hawaiian, Alaskan, Mediter-
ranean. 7-14 days year-round. Approved for 20-24 CME
Cat. 1 credits (AMA/PRA) & AAFP prescribed credit.
Distinguished professors. FLY ROUNDTRIP FREE ON
CARIBBEAN, MEXICAN, & ALASKAN CRUISES.
Execellent group fares on finest ships. Registration limited.
Pre-scheduled in compliance with present IRS require-
ments.
Information: International Conferences, 189 Lodge
Ave., Huntington Station, N.Y. 11746. (516) 549-0869.
ARE YOU A SAINT MICHAEL’S ALUMNUJ'
Saint Michael's Medical Center, Newark, NJ, a 117 year d
teaching hospital, is forming a medical alumni association, 'i;
are seeking some 5,000 physicians who served as reside
and interns. Over the years many of our former house si f
members have relocated making consistant communicatil'
difficult.
Our alumni association will be oriented towards four got
professional, medical, social and educational. Plans
already being made for a medical reunion dinner and sy
posium in the fall.
If you are a former member of Saint Michael's house staff
know another staffer’s whereabouts, please call (2>
877-5494 or write to:
SAINT MICHAEL’S MEDICAL CENTER
268 Dr. Martin Luther King, Jr. Blvd.
Newark, NJ 07102
attn: Office of Public Affairs
POST-GRADUATE
MEDICAL SCHOOL
WINTER COURSE SCHEDULE
DECEMBER
12/3-6 350 Neurosurgery NYC/1984 (Grand Hyatt)
12/3-7 314. Toxicology and Pharmacology
12/10-12 321 Managing Clinical Problems
in the Elderly
12/17-22 603 Computed Tomography
(Grand Hyatt)
12/15-16 733 Basic Review of Pathology and
Radiology for Urologists
JANUARY
1/9-6/26/85 302. Internal Medicine Board Review
Wednesdays 4:00 to 7:00pm
MARCH
3/11-15 321b Managing Clinical Problems
in the Elderly
(Cerromar Beach Hotel, Puerto Rico)
3/11-15 603b. Computed Tomography
(Cerromar Beach Hotel)
3/18-22 304 Seminar in Advanced
Rheumatology
3/25-29 100. Anesthesiology Board Review IV
3/30-31 735. Lasers in Urology
FOR INFORMATION NYU Post-Graduate
Medical School
550 First Avenue New York, NY 10016
(212) 340-5295 (24hr. service)
NEW YORK
FERTILITY RESEARCH
FOUNDATION, INC.
For the Investigation of
Problems of Human Infertility
The Foundation provides a complelj
diagnostic and consultation service for ir
fertile couples. Investigations are cor
ducted by well-known specialists in cor
junction with consultants in the variOL
fields of medicine related to infertility.
The Foundation is supported by an ir
house modern laboratory equipped to d
most tests required for diagnosis an
treatment. Literature on request.
•
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
900
9 School, Medical Education Bldg.,
New Brunswick
(UMDNJ and AMNJ)
6 Management of Congenital
Infections
9 A.M.— Freehold Area Hospital
(AMNJ)
6 lmmunoregulation: Basic
3 Concepts and Applications
4-6 P.M— Institute for Medical
Research, Copewood St„ Camden
(Institute for Medical Research
and AMNJ)
7 Medicine Morbidity and Mortality
Conference
8-9 A.M.— Rutgers Medical School,
Medical Education Bldg., New
j Brunswick
(UMDNJ and AMNJ)
2 Clinical Immunology
1 :00 P.M. — VA Medical Center,
1 Lyons
(AMNJ)
2 What Is New in Allergy?
8-9:30 P.M. —Schering Corporation,
Kenilworth
(NJ Allergy Society, Schering
Corp., and AMNJ)
1 3 Management of Abdominal
Emergencies
1 1:00 A.M. — St. Joseph’s Hospital
and Medical Center, Paterson
(AMNJ)
13 The Prevention and Reversibility
of Heart Disease
12 noon-1 P.M. —Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
13 Indications, Techniques, and
Results in Coronary Thrombolysis
5-7:30 P.M — Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
NEUROLOGY/ PSYCHIATRY
Nov.
1 Psychotherapy Outcome Research
8 The Wish To Be Held
15 Smoking, Personality, and Health
29 Humor In Psychotherapy
12 noon- 1 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
2 Lecture Series
9 1:30-5:30 P.M. — Trenton
16 Psychiatric Hospital
23 (NJ Division oj Mental Health and
30 Hospitals and AMNJ)
3 Clinical Issues in Adoption
8:30 AM. -5 P.M. — Fair Oaks
Hospital, Summit
(Fair Oaks Hospital and AMNJ)
5 Psychosomatic Disorder Followed
by a Tic
8:15-10:30 P.M. — 192 Chittenden
Road, Clifton
(Essex Psychiatric Seminar and
AMNJ)
7 Therapeutic Touch— Research
and Clinical Findings
1-2:30 P.M. — VA Medical Center,
Lyons
(VA Medical Center and AMNJ)
7 Louis Loeser Memorial Lecture
8- 1 0 P.M. — South Mountain School.
South Orange
(NJ Psychiatric Association, NJ
Medical School, and AMNJ)
8 Certain Aspects of Forensic
Psychiatry Applicable to the
Chronic Care Psychiatric Hospital
1 -3 P.M. —Essex County Hospital
Center, Cedar Grove
(Essex County Hospital and
AMNJ)
1 0 Prevention of Mental Illness in
Children
9 AM. -4 P.M. — The Mountainside
Hospital, Montclair
(The Mountainside Hospital and
AMNJ)
14 Industrial /Occupational Medicine
and Psychiatry
9: 1 5 AM. -4:30 P.M. — Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
15 Topic To Be Announced
8:30 P.M. — Hackensack Medical
Center
(NJ Psychoanalytic Society and
AMNJ)
1 5 Psychopharmacology I
29 Psychopharmacology II
3-4 P.M. — Ancora Psychiatric
Hospital, Hammonton
(AMNJ)
1 7 What’s New in the Management of
Cerebrovascular Disease?
8 AM. -4 P.M — Marriott, Saddle
Brook
(UMDNJ-NJ Medical School and
AMNJ)
19 Lecture Series
8:30- 10:30 P.M. — 301 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
Dec.
3 Survival Guilt with Somatic
Symptoms
8: 1 5- 1 0:30 P.M. —4 Garden Place.
Nut ley
(Essex Psychiatric Seminar and
AMNJ)
3 When the Patient Abuses Drugs:
Skills for the Outpatient Therapist
1 4 P.M. — Fair Oaks Hospital.
Summit
(Fair Oaks Hospital and AMNJ)
6 Medical Hypnosis Course
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jer-
sey. This special issue illuminates the beginnings of our
health care system and the growth of medical care: essays
highlight those talented individuals who devoted themselves
to this system, and commentaries present the development
of specialized care in associated fields of medicine. Plus a
special photography section highlighting three statewide
exhibits.
Copies of this issue are available by sending $5.00
(check or money order) to MSNJ, Two Princess Road, Law-
renceville, NJ 08648. All MSNJ members will receive one copy
of this issue.
Name
Enclose a $5.00 check or money order for each copy.
3L. 81— NUMBER 10— OCTOBER 1984
901
13 4-8 P.M.— Carrier Foundation,
Belle Meade
(Carrier Foundation and AMNJ)
12 Sleep Disorders
1:30-2:30 P.M.— Rutgers
Community Health Plan, 57 U.S.
Hwy. # 1 , New Brunswick
(Rutgers Community Health Plan
and AMNJ)
13 Becoming a Psychotherapist
12 noon-1 P.M. — Carrier
Foundation, Belle Meade
(Carrier Foundation and AMNJ)
1 3 Child Sexual Abuse
8:30 AM. -5 P.M. —Fair Oaks
Hospital, Summit
(Fair Oaks Hospital and AMNJ)
20 Coordination of Psychiatric
Treatment in the Hospital and
Community
3:00 P.M. —Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital)
1 7 Lecture Series
8:30- 10:30 P.M. —301 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
OBSTETRICS/GYNECOLOGY
Dec.
3 Prophylactic Mastectomy and
Treatment of the Second Breast
8 A.M. -5 P.M. — UMDNJ-Rutgers
Medical School, Medical Education
Bldg., New Brunswick
(UMDNJ-Rutgers Medical School)
4 Psychosocial Issues and
Interactions in Breast Disease
9 AM. -4 P.M. — UMDNJ-Rutgers
Medical School, Medical Education
Bldg., New Brunswick
(UMDNJ-Rutgers Medical School)
PATHOLOGY
Nov.
1 7 Surgical Pathology of the Breast:
Diagnosis and Therapeutic
Implications
9AM.-1 P.M. — Rutgers Medical
School, Piscataway
(NJ Society of Pathologists and
AMNJ)
PEDIATRICS
Nov.
6 Newer Aspects of Pneumonia in
Infants and Children
8:30-9:30 AM. — Newark Beth Israel
Medical Center
(Newark Beth Israel Medical
Center and AMNJ)
7 Current Diagnosis and
Management of Pediatric
Rheumatologic Diseases
8:30 A.M. -2 P.M. —Rutgers Medical
School, Piscataway
(Arthritis Foundation, NJ Chapter,
NJ Rheumatism Association, and
AMNJ)
9 The Current Approach to the
Investigation and Management of
Urinary Tract Infections in
Children
8-9:30 AM. — Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
RADIOLOGY
Nov.
7 Newer X-ray Imaging Techniques
21 1:30-2:30 P.M. — Rutgers
Community Health Plan, 57 U.S.
Hwy. #1, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
8 Current Status of Carotid Imaging
7:30 P.M — Saint Barnabas Medical
Center, Livingston
(NJ Institute of Ultrasound in
Medicine. Radiological Society of
NJ, and AMNJ)
20 Nuclear Magnetic Resonance
12 noon— St. Maiy's Hospital,
Orange
(AMNJ)
2 1 Radiation Therapy Oncology
Group
6:30-9:30 P.M. — The Manor, West
Orange
(Radiotherapy Section, AMNJ)
Dec.
5 NMR— Clinical Imaging
1 :30 P.M. —Essex County Hospital
Center, Cedar Grove
(AMNJ)
15 Topic To Be Announced
7:30-10 P.M. —Saint Barnabas
Medical Center, Livingston
(NJ Institute of Ultrasound in
Medicine and AMNJ)
20 Radiology Meeting
7:30 P.M. — Saint Barnabas Medical
Center, Livingston
(Radiological Society ofNJ and
AMNJ)
SURGERY
Dec.
1 Clinical Meeting
All Day Session — UMDNJ-NJ
Medical School, Newark
(NJ Chapter, American College
Surgeons and AMNJ)
6 Surgical Treatment of Morbid
Obesity
1 2 noon — West Jersey Hospital,
Camden
(AMNJ)
14 Surgical Emergencies in the
Newborn
8-9:30 AM. — Overlook Hospital.
Summit
(Overlook Hospital and AMNJ)
1 8 Arterial Clot Lysis Using
Streptokinase
8- 1 0 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society ar
AMNJ)
SURGICAL SPECIALTIES
Nov.
27 Breast Reconstruction After
Mastectomy
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society ar
AMNJ)
MISCELLANEOUS
Nov.
1 Medical Hypnosis Course
8 4-8 P.M. —Carrier Foundation, Be
15 Meade
29 (Carrier Foundation and AMNJ)
1 4 Withholding or Withdrawal of Li
Support— Legal and
Ethical /Moral Aspects
8:30 AM. -3:30 P.M. — Hilton Inn,
Tinton Falls
(NJ Society of Critical Care
Medicine and AMNJ)
Dec.
5 DRG— Cost Containment
10:30 AM. — St. Maiy’s Hospital.
Passaic
(AMNJ)
29 Nuclear Holocaust Prevention
12 noon-1 P.M. — Carrier
Foundation, Belle Meade
(Carrier Foundation and AMNJ)
902
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
ETTERS TO THE
EDITOR
ji
Of
Dr. Martland’s Ashes;
Dr. Leon J. Anson
>r. Maitland's Ashes
July 5, 1984
ear Doctor Krosnick:
Your response to Dr. James
ellet’s letter to the Editor (April
384) in which he criticized you for
Ising a photograph of Dr. Harrison
Martland on The Journal cover, a
garette between his lips while per-
trming an autopsy, was cogent to
le extent that it was based on the
istorical perspective of smoking.
Unanswered, however, was Dr.
ellet’s comment on Dr. Martland’s
nsensitivity of the ashes dangling
ad about to fall on the remains of
ae cadaver.” Like many others, he
It better able to concentrate on the
latter at hand with a cigarette be-
veen his lips even without puffing.
More to the point, ashes never fell on
a cadaver; one of the interns near
him (and they always were crowded
around the table) would hold a sheet
of paper under the cigarette and tap
it to dislodge the ashes at the ap-
propriate time. Martland’s assistant
held a small hose and washed blood
from the organ whenever it was ad-
vanced toward him, which was fre-
quently; always respect, always
cleanliness.
If the individual on the table being
studied could have noted the in-
tensity of Martland’s search for the
truth and the intensity of the in-
tern’s attention to his remarks, the
cigarette would have been forgiven.
I am sure that Dr. Bellet would have
tolerated the cigarette if he had had
the good fortune of attending one of
Dr. Martland’s renowned autopsy
performances.
(signed) Samuel Berg, M.D.
Dr. Leon J. Anson
July 20, 1984
Dear Doctor Krosnick
When we lose a revered colleague,
it does not seem enough for The
Journal to announce on the obitu-
ary page just the bare facts of his or
her career. I enclose such a fact
sheet for publication, but I feel it
more fitting that the information be
conveyed in the following way:
On June 21, 1984, Leon J. Anson,
M.D., died, after 44 years of dedi-
cated and compassionate service to
his Union County patients. Bom in
New York City on February 5, 1913,
Dr. Anson graduated from the Medi-
cal College of Virginia in 1938. After
further training at Conemaugh Val-
ley Memorial Hospital, Johnstown,
PA, and Newcomb Memorial Hospi-
tal, Vineland, he entered private
practice in Fanwood in 1939. He
continued there until 1978, except
for 2 years during the Second World
War when he served as a captain in
the Air Force. He was affiliated with
Overlook Hospital, where the Family
Practice Service remains as a living
tribute to him; he initially was as-
sociated with its development, and
remained the zealous custodian of
its growth and direction, and
drafted the original bylaws for the
department.
Dr. Anson was a Renaissance
man— he practiced modem medi-
cine expertly, but in an old-world
way. Always available to his patients
(he never took vacations), whether
their need was for medical treat-
ment, or help in a family crisis; he
knew all the members of each house-
hold, as he cared for three and even
four generations of them.
Dr. Anson was a serious student
of Shakespeare, with a great love for
the sonnets. He also was a
Wagnerite, who could amuse his
opera buff friends by singing along
with Callas, as well as Melchior. His
expert knowledge and fine collection
of oriental mgs added to the luxuiy
of sharing musical sessions in his
home. As with his medicine, he con-
tinued to read and add to his knowl-
edge and understanding of these
interests to the end of his days.
His effectiveness in organizing
physician colleagues in the hospital,
the Medical Society of New Jersey,
and the Summit Medical Society in
large measure was due to the energy
and integrity with which he set
about each task but his wry humor
and instinct for bringing people
together, were the means by which
he crafted an extended family
throughout the hospital.
He is survived by his wife, Betty
Bowers Anson; a daughter, Judith
Anson Lee; and four grandchildren,
Tadd, Maya, Joshua, and Jared Lee,
of Vista, California; also a sister,
Doris Krumholz of New York City.
I trust you will find room for some
of this more alive portrait of Leon
and perhaps in the future The
Journal will encourage the sub-
mission of tributes, instead of bare
facts.
(signed) Margaret E. Symonds, M.D.
'OL. 81— NUMBER 10— OCTOBER 1984
903
Book reviews
Alzheimer's Disease;
Current Pediatric
Diagnosis and Treatment;
Illustrated Textbook of
Gynaecology; Law of
Medical Practice in
Pennsylvania and New
Jersey; Review of Medical
Microbiology
Alzheimer's Disease: The
Standard Reference
Barry Reisberg, M.D., (ed). New
York, NY, The Free Press (Mac-
millan Division), 1983. Pp. 475. Il-
lustrated.
Bariy Reisberg, M.D., assistant
professor, department of psychiatry.
New York University Medical Center,
has composed a textbook and
brought together all of the research
and information on the clinical and
pathological aspects of Alzheimer’s
disease (AD). World-renowned ex-
perts have written and covered the
history, background of AD, path-
ology, neuroehemistry, epidemiol-
ogy, and genetic aspects; the clinical,
differential, and psychometric
diagnoses, as well as diagnostic
procedures and therapeutic treat-
ments are likewise discussed.
By presenting this volume of the
most recent research, he hopes he
has laid the groundwork for future
research.
AD is the fourth leading cause of
death in the United States and the
major cause for nursing home ad-
missions among Americans. In its
mild to moderate stages, it results in
early retirement and social with-
drawal for millions of people
throughout the world. The incidence
of AD continues to grow as the dis-
ease of the century. Thousands also
are confined in state and veterans
hospitals, and a majority of persons
are cared for in their own homes by
relatives and home health aides, re-
quiring continuous supervision and
care.
This neuropathological entity was
described clearly by Alois Alzheimer
in 1907. Interestingly, it was de-
scribed by Sophocles in the 5th cen-
tury, B.C., and reinforced by
Shakespeare in his description of
the behavior patterns of King Lear.
Often terms such as “senile demen-
tia” or “presenile dementia” or “pri-
mary degenerative dementia" are
used clinically to describe cognitive
abnormalities, not invariably as-
sociated with AD type brain damage.
Many theories as to cause still are
being followed in research labora-
tories around the world.
The purpose of this volume is to
establish a milestone for the medical
profession’s understanding of AD.
One fact is made clear in many of the
discussions: AD is not a normal
characteristic of aging. It may be
that AD, like hypertension and
atherosclerosis, is a multifactorial
disease, and if this is true, then the
medications that are suitable for the
management of the symptoms have
yet to be found. However, one medi-
cation does stand out, the ergoloid
mesylates. It is the most widely used
and investigated cerebral metabolic
enhancing agent. It has been postu-
lated by Reisberg that ergoloid
mesylates may be more effective in
senile dementia of AD than in those
with multi-infarct dementia.
In comparison with placebo, or
with papaverine, the ergoloid
mesylates have shown a good
margin of safety in elderly patients
and somewhat superior results.
Alzheimer's Disease is indeed
well recommended for all clinicians,
students, and health science li-
braries.
Hariy M. Poppick, M.D.
Current Pediatric
Diagnosis and Treatmem
8th Edition
C. Henry Kempe, M.D., Henry K. Sil
ver, M.D., and Donough O'Brien
M.D., (eds). Los Altos, CA, Langt
Medical Publications, 1984. Pp
1164. ($27)
Dr. Kempe died recently. The
world pediatric community will mis:
him. He will be remembered fof
many contributions including alert
ing us to the problems of child abuse
and for his shepherding thi:
marvelous text through eight won
derful editions.
I have been practicing pediatric:
for 30 years. Nonetheless, this tex
provided some new, useful, o
interesting fact every ten pages. It i:
a good book to keep on your desk fo:
use when puzzling problems arise o:
to peruse during quiet moments, as|
suming that taking care of childrerj
ever allows quiet moments.
The present federal adminis
tration is not likely to be pleasec
with the chart on page 671 whicl
suggests that early surgical inter?
vention is not recommended for ;
newborn if severe cerebral birtl
trauma and gross disabling conj
genital abnormalities are present
On the other hand they might lik<
the suggestion on page 324 tha
$200,000,000 might be saved eaclj
year by practically eliminating
tonsillectomy and adenoidectormi
and that this money better could b<,
spent elsewhere.
In the wake of our recent epidemic1
of viral influenza, we all have seerj
cases of benign acute childhooc
myositis. I am happy to note tha:
this subject is included in the tex
though I am disappointed that the
value of the serum CPK in confirm
ing the diagnosis is not mentioned
I recommend this book to all phy
sicians who have children or set
children in their practices.
Solomon J. Cohen, M.D
Illustrated Textbook of
Gynaecology
MacKay, Beischer, Cox, and Wood ;
Artarmon, Australia, Holt
Saunders, Ltd., 1983. Pp. 496. II
lustrated. ($39.50)
This textbook is exactly what the
title implies. It is a standard treatise
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
904
in basic medical and operative
ynecology which contains many
ihotographs of gynecologic eon-
litions. The photographs and il-
astrations reflect the authors’
>road expertise in that they are nu-
nerous and reveal a variety of com-
non and not-so-common con-
litions. Although all the photo-
;raphs are in black and white, they
yell illustrate the conditions they
yish to present. Hopefully, however,
uture editions will include some
olor photographs.
Each chapter starts with an over-
iew of the topic which is to be pre-
ented and there is little overlap be-
ween subjects. The Australian
uthors possess the gift of language
hat their English counterparts do.
'his ability, to use the mother
anguage with style and wit, often is
lissing with some of our American
yriters.
A minor problem may be the read-
r’s unfamiliarity with some of the
)cal instruments, i.e., a Devine’s
fame (a type of self-retractor). The
tudent, however, does get an in-
ight into modern gynecologic
hinking and techniques as prae-
iced on another continent.
The text is recommended to stu-
ents and gynecologists who wish to
roaden their understanding of the
ubjeet by being exposed to the state
f the art in another modem com-
uinity. G.F. Hansen, M.D.
?he Law of Medical
Practice in Pennsylvania
md New Jersey
ost Peters, Stahl, Peters, Fineberg,
nd Kroll. Rochester, NY, The Low-
ers Cooperative Publishing Co.,
984. Pp. 1080.
The authors of The Law of Medi-
!
OL. 81— NUMBER 10— OCTOBER 1984
cal Practice in Pennsylvania and
New Jersey have succeeded in com-
piling a most instructive and read-
able text dealing with a difficult sub-
ject. This comprehensive volume is
a useful and welcome reference and
resource tool for physicians, at-
torneys, hospital administrators, in-
surance professionals, and others
wishing to acquire knowledge of
medicolegal matters.
The text addresses various state
regulations, statutes, and judicial
decisions that concern the entire
spectmm of medical practice in New
Jersey and Pennsylvania. The book
begins with chapters covering cur-
rent issues affecting medical prac-
tice starting with a brief history of
the medical system in the United
States and encompassing issues
such as medical education, health
care facilities, hospital adminis-
tration and regulation, and medical
staff issues.
Chapters 4 to 8 perhaps are the
most useful to physicians and at-
torneys. Chapter 4 presents a
thoroughly referenced and com-
prehensive overview of the law of
medical malpractice and the liti-
gation system as both have evolved
in New Jersey and Pennsylvania
Chapter 5 presents useful infor-
mation with regard to physician
licensure in both states. Chapters 6
and 7 set forth in detail the various
regulatory requirements in both
states, including public health mat-
ters, reporting requirements, con-
trolled substances, and a review of
the laws and situations which might
expose a physician to criminal lia-
bility. The final chapter is a thought-
provoking presentation illustrating
a wide range of medical problems
requiring the application of ethical
decision making.
The 26 appendices cover many
areas discussed in the text and in-
clude schedules of controlled sub-
stances in both states, a legal
glossary, codes of ethics, standard
medical abbreviations, sample legal
documents, and sample medical re-
cords.
The authors are to be con-
gratulated for their scholarly yet
practical approach to a most dif-
ficult subject.
James E. George, M.D., J.D.
Review of Medical
Microbiology
C. Jawetz, J.T. Melnick, E.A.
Adelberg (eds). Los Altos, CA, Lange
Medical Publications, 1984. Pp. 557.
($18.50)
This is the 16th edition of the very
popular medical microbiology hand-
book which first was published in
1 954 by the same authors; every two
years a new edition is produced so
that the material is current.
This edition contains the latest
materials of acquired immunodefi-
ciency syndrome genetics, virology,
and chemotherapy. The literaiy style
is unchanged with every line
“chockful” of information and facts,
a superb manner for reviewing ma-
terial. On the other hand, medical
students seeing this material for the
first time may be overwhelmed by
the condensation and lack of flow of
material. The success of this series
is illustrated by the translation into
12 languages. In 535 pages, every
phase of basic and medical micro-
biology is reviewed. The present
outline, photographs, charts, and
references are first rate.
This series is a favorite of mine
and my son— a medical student.
Leon G. Smith, M.D.
905
OBITUARIES
Drs. Anson; Barach;
Barbarosh; Bianco;
Bomstein; Cassidy; Franz;
Grieco; Keates;
Laufenberg; Petrosino;
Pores; Rosen; Rossi;
Sawyer; Sciortino;
Spivack; Williams
Dr. Leon J. Anson
A general practitioner in Garwood
for almost 40 years, Leon J. Anson,
M.D., died on June 21, 1984, at his
home in Mountainside. Bom in
1913, Dr. Anson received his medi-
cal degree from the Medical College
of Virginia in 1938. He was a mem-
ber of our Union County component,
and board certified in family prac-
tice. Prior to his retirement in 1978,
Dr. Anson had been affiliated with
Overlook Hospital, Summit. He
served as town physician in Gar-
wood for several years and was
police surgeon in Mountainside for
almost 15 years.
Dr. Richard L. Barach
The head of radiology at The Medi-
cal Center at Princeton, Richard L.
Barach. M.D., died on July 2, 1984.
In addition to his duties at The
Medical Center, Dr. Barach was a
consultant for the Carrier Foun-
dation. Belle Mead, and Princeton
University. Bom in 1922, Dr. Barach
earned his medical degree from Yale
University School of Medicine in
1949. For the past 25 years. Dr.
Barach had made his home in
Princeton. A member of our Mercer
County component and of the
American Medical Association. Dr.
Barach was a Fellow of the American
College of Radiology and a
Diplomate of the American Board of
Radiology.
Dr. Allan B. Barbarosh
At the untimely age of 48, Allan B.
Barbarosh, M.D., died of cancer on
June 25, 1984, in Seattle, Washing-
ton. An obstetrician/gynecologist in
Dover, Dr. Barbarosh was bom in
Newark, and was graduated from
Chicago Medical School, Illinois, in
1961. He was a member of our
Morris County component, and of
the American Medical Association.
Dr. Barbarosh was board certified in
his specialty, and a Fellow of the
American College of Obstetricians
and Gynecologists. He had been af-
filiated with Dover General Hospital,
and was chairman of their depart-
ment of obstetrics and gynecology.
Dr. John J. Bianco
Word has been received of the
death of John James Bianco, M.D.
Bom in 1915, Dr. Bianco was gradu-
ated from Temple University School
of Medicine, Philadelphia in 1941. A
retired member of our Cumberland
County component, living in Florida
Dr. Bianco was a member of the
American Medical Association, a Fel-
low of the American College of Sur-
geons, and a Diplomate of the Ameri-
can Board of Obstetrics and Gyne-
cology.
Dr. Paul K. Bomstein
A member of our Monmouth
County component, Paul Kenneth
Bomstein, M.D., died on June 15,
1984. An internist, with an office in
Asbury Park for many years. Dr.
Bomstein was bom in 1910 in
Paterson. He received his medical
education at Indiana University
School of Medicine, Indianapolis, In-
diana, graduating in 1933. Dr.
Bomstein was board certified in
internal medicine, and was a Fellow
of the American College of Physi-
cians and of the American College of
Cardiology. He had been affiliate
with Monmouth Medical Cente
Long Branch; Metropolitan Hospita
New York City; and Paul Kimba
Hospital, Lakewood. Dr. Bomstei
also served as a consultant to
number of hospitals including D(
borah Heart and Lung Cente
Browns Mills. Dr. Bomstein was
recipient of MSNJ’s Golden Mer
Award in 1983 in recognition of 5
years of medical practice.
Dr. Herbert E. Cassidy
At the age of 56, Herbert Eugen \
Cassidy, M.D., a member of op;
Hudson County component, died o
May 31, 1984. Graduating from th
State University College of Medicini
New York, in 1956, Dr. Cassidy oper
ed a practice specializing in ped
atries in northern New Jersey. Du;i
ing his career. Dr. Cassidy was aj|
filiated with Jersey City Medic;
Center and Bayonne Hospital. D
Cassidy was a member of the Amer j
can Medical Association and a Fe!
low of the American College (
Sports Medicine.
Dr. Ronald L. Franz
At the untimely age of 36, RonaJ
Leslie Franz, M.D., died July 1
1984. Bom in New York, Dr. Frar
received his medical education froi
the Free University of Bmsseli
Belgium in 1969. He completed a
internship at Coney Island Hospita
New York, in 1977 and a resident
in 1978. At the time of his death, D;
Franz was an internist with a pr
vate practice in Morrisville, Peni
sylvan i a Dr. Franz was a member <
our Mercer County component an
of the American Geriatric Societ
He was affiliated with Helene Ful1
Medical Center, Trenton.
Dr. Emil H. Grieco
We just have learned of the deat
on October 20, 1983, of Emil Hem
Grieco, M.D., a member of or
Hudson County component. Bom i|
1907 in Bayonne, Dr. Grieco r<!
ceived his medical degree from Ne
York University School of Medicirjl
in 1933, and returned to his nativ
city where he established a practic
in cardiology. He was a member <|
the American Medical Association,
Fellow of the American College (ij
Physicians, and a Diplomate iij
internal medicine. He had been a
906
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
filiated with Bayonne Hospital, ser-
ving for several years as the director
pf the department of medicine. In
1983, Dr. Grieeo received MSNJ's
Golden Merit Award, honoring his
50 years in medicine.
Dr. George H. Keates
George H. Keates, M.D., an in-
jtemist in Linwood for the past 22
/ears, died in Shore Memorial Hos-
pital, Somers Point, at the untimely
age of 53, on June 7, 1984. Bom in
Atlantic City, Dr. Keates received his
!medical degree from Temple Univer-
sity School of Medicine, Philadel-
phia in 1956. Dr. Keates was af-
filiated with Shore Memorial Hospi-
tal, and had served as president of
the hospital staff in 1975. He had
been medical director of the
•Linwood Convalescent Center, and
Was active in community affairs
having served as school physician
or the Linwood public school sys-
:em and for Oakcrest High School.
Dr. Keates also was a certified avia-
ion medical examiner for the Feder-
al Aviation Administration.
Dr. Joseph W. Laufenberg
Word has been received of the
leath of Joseph William Laufenberg,
VI. D., on May 5, 1984. Bom in 1915,
Jr. Laufenberg earned his medical
degree at Hahnemann Medical Col-
ege, Philadelphia in 1941. An ab-
dominal surgeon. Dr. Laufenberg
vas affiliated with Helene Fuld
Vledical Center, Trenton. A retired
aiember of our Mercer County eom-
aonent and a member of the Ameri-
can Medical Association, Dr.
-aufenberg retired to Plumstead
Township three years ago.
Dr. Carmen P. Petrosino
Carmen Patrick Petrosino, M.D.,
lied on February 15, 1984. A mem-
>er of our Hudson County compo-
lent. Dr. Petrosino was an obstetri-
ian, with a practice in Hoboken. He
vas affiliated with Riverside Hospi-
al, Seeaucus, and St. Mary Hospital,
doboken. Graduating in 1950 from
he University of Bologna Italy, Dr.
Petrosino came to the United States
n 1953. Dr. Petrosino was a
)iplomate of the American Board of
Obstetrics and Gynecology, a Fellow
>f the American College of Ob-
itetrics and Gynecology and of the
American College of Surgery, and a
member of the American Medical As-
sociation.
Dr. Ira H. Pores
Word recently was received of the
death on February 12, 1984, of Ira
Howard Pores, M.D., a member of
our Essex County component. Only
39 years old at the time of his death,
Dr. Pores was bom in New York City
and received his medical degree
from the State University of New
York at Buffalo in 1973. He was a
cardiologist with offices in Millbum.
Dr. Pores was a member of our Essex
County component, and had been
board certified in internal medicine.
Dr. Charles D. Rosen
An internist in East Orange for 48
years, Charles Daniel Rosen, M.D.,
died in East Orange General Hospi-
tal on June 9, 1984. Bom in New
York City in 1910, Dr. Rosen was
graduated from Long Island College
of Medicine, Brooklyn, in 1935. He
was a member of our Essex County
component, a member of the Ameri-
can Medical Association, and a Fel-
low of the American College of Chest
Physicians. He had been affiliated
with Presbyterian Hospital, Newark;
East Orange General Hospital; and
the Geriatric Center, Belleville.
Dr. John R. Rossi
John Richard Rossi, M.D., a re-
tired member of our Hudson County
component, died on March 2, 1984.
Bom in 1910, Dr. Rossi received his
medical degree from the Faculty of
Medicine of Rome, Italy in 1938. He
completed an internship at St. Fran-
cis Hospital, New York. An anesthe-
siologist, Dr. Rossi was affiliated
with Bayonne Hospital during his
career and served as president of the
Bayonne Medical Society in 1959.
Dr. Blackwell Sawyer
In his 85th year, Blackwell Sawyer,
M.D., died on June 24, 1984, at Com-
munity Memorial Hospital, Toms
River. Born in Elizabeth City, North
Carolina, Dr. Sawyer received his
medical degree from Jefferson Medi-
cal College in 1924. He practiced
family medicine in Toms River for
over 40 years until 1970 when he
moved to Island Heights. Dr. Sawyer
was a member of our Ocean County
component, and a member of the
American Medical Association. He
was affiliated with Paul Kimball
Hospital, Lakewood, and Communi-
ty Memorial Hospital, Toms River. In
1948, Dr. Sawyer received the Na-
tional Outstanding Country Doctor
Award.
Dr. Joseph Sciortino
At only 63 years of age, Joseph
Sciortino, M.D., died at United Hos-
pitals Medical Center, Newark on
June 10, 1984. Dr. Sciortino was
bom in Bellefonte, Pennsylvania,
and was graduated from the Faculty
of Medicine, University of Palermo,
Italy, in 1955. From the age of 7 until
1958, Dr. Sciortino lived in Italy, re-
turning to the United States in that
year and establishing his practice in
Elizabeth. He was a member of our
Union County component, and had
been chief anesthesiologist at St.
Vincent’s Hospital, Montclair, and
on the staff at Alexian Brothers Hos-
pital, Elizabeth.
Dr. David Spivack
A senior member of our Union
County component, David Spivack
M.D., died June 24, 1 984. A native of
New York City, Dr. Spivack received
his medical degree from New York
University’s College of Medicine in
1933. He established a practice in
general surgery in Elizabeth, and
had been affiliated with St. Eliza-
beth’s, Alexian Brothers, and Eliza-
beth General Hospitals in that city.
Dr. Spivack was a Fellow of the Inter-
national College of Surgeons; in
1983, he received MSNJ’s Golden
Merit Award in recognition of his 50
years of medical practice. He was 75
years old at the time of his death.
Dr. David P. Williams, Jr.
An internist in Boonton for many
years, David Porter Williams, Jr.,
M.D., died on June 23, 1984. Dr. Wil-
liams was bom in Bakerstown,
Pennsylvania in 1912, and received
his medical degree from Western Re
serve University School of Medicine,
Cleveland, Ohio, in 1938. He was a
member of our Morris County com-
ponent, and a member of the Ameri-
can Medical Association. He had
been affiliated with S(. Clare Hospi-
tal, Denville, and Riverside Hospital,
Boonton.
rOL. 81— NUMBER 10— OCTOBER 1984
907
Author Information
Style
Sheet
The Journal is the
official organ of the
Medical Society of New
Jersey. The goals of The
Journal are educational
and informational. All
material published in The
Journal is copyrighted by
MSNJ.
CONTENT
The educational content of each
issue appears as scientific articles,
based on research, original concepts
relative to epidemiology of disease,
and treatment methodology; case re-
ports based on unusual clinical ex-
periences; review articles; clinical
notes, succinct items on some
aspect or new observation or tech-
nique of a ease experience; and
special articles, which include evalu-
ations, policy and position papers,
and reviews of nonseientific sub-
jects. Other topics include commen-
tary (critical narration); medical his-
tory; therapeutic drug information:
pediatric briefs; nutrition update;
and an opinion column. Editorials
are prepared by the Editor and by
guest contributors on timely and rel-
evant subjects; editorials are the re-
sponsibility of the author. The Doc-
tors' Notebook section contains or-
ganizational, informational, and ad-
ministrative items from MSNJ and
from the community. Letters to the
Editor and book reviews are wel-
come and will be published as spa^e
permits. The principal aim in the
preparation of a contribution
should be relevance to diagnosis and
treatment and to education of pa-
tients and professionals. Preference
will be given to professional authors
from New Jersey and to out-of-state
lecturers who submit a suitable
manuscript based on a presentation
made in New Jersey.
ASSIGNMENT OF COPYRIGHT
In compliance with the Copyright
Revision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statment accompanying
material offered to The Journal of
the Medical Society of New Jersey
must contain the following language
and must be signed by all authors:
“In consideration of The Journal
of the Medical Society of New Jersey
taking action in reviewing and edit-
ing my submission, the author(s)
undersigned hereby transfers, as-
signs, or otherwise conveys all
copyright ownership to the Medical
Society of New Jersey, in the event
that such work is published in The
Journal. MSNJ."
SPECIFICATIONS
Submit two manuscripts that
must be typewritten and double-
spaced on 8V2” by 1 1 " paper.
Statistical methods used in articles
should be identified. Acknowl-
edgements will be made only for
specific preparation of an essential
part of the manuscript.
Authors are asked to seek clarity,
accuracy, and originality; attention
to details of grammar, spelling, and
typing are important.
The title page should include the
full name, degrees, and affiliations of
all authors, and the name and ad-
dress of the author to whom reprint
requests should be sent.
The author should submit a 40-
word abstract to be used at the be-
ginning of the article.
Tables must be typewritten and
double-spaced on separate 8V2" by
1 1" sheets, with a title and number.
Symbols for units should be con-
fined to column headings, and ab-
breviations, properly explained,
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Medic us:
1. Goldwvn RM: Subeutaneor
m as tec to my. J Med Soc
74; 1050-1052, 1977.
2. Dixon WJ, Massey FJ: Introdu
tion to Statistical Analysis. Ne
York. NY, McGraw-Hill, 1969,
42-48.
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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!DL. 81— NUMBER 10— OCTOBER 1984
MEDICAL PRACTICE
SALES AND APPRAISALS
We specialize in the valuation and selling of
medical practices. If interested in buying or selling
a medical practice, contact our Brokerage
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Or call Susan L. Hughes, Physician
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909
It’s A Major Medical Explosion
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are all going ahead with major expansion programs . . .
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
910
CLASSIFIED ADVERTISEMENTS
JVESTHESIOLOGIST — Seeks group or
artnership, 1976, Far Eastern Univer-
ity Hospital. Available January 1985.
elephone 212-345-2822.
VTERNIST — Board certified, board
ugible cardiologist; 33, trained in Swan-
anz, temporary pacemaker. Echo. Three
?ars experience internal medicine. Pos-
ion wanted in area internal medicine or
irdiology. Phone 215-592-1843 or reply
» Box No. 99, JMSNJ.
■VTERNIST — Board eligible, looking for
ib opportunity or group practice. Avail-
ole immediately. 201-463-8571.
BSTETRICS/ GYNECOLOGY — Board
igible, NJ licensed, subspecialty fellow-
lip experience in Micro-surgery, hys-
■roscopy, infertility, artificial insemina-
on, gyn-endocrinology. Seeks practice
oportunity. Available now. Write Box No.
3. JMSNJ.
EDIATRICIAN— Board eligible, 33, with
years experience in general pediatric
■actice, strong neonatal background,
/ailable July 1985. Desires opportunity
New Jersey. Contact Box No. 101,
iidSNJ.
URGICAL ASSISTANT — Board
i'rtified ophthalmologist would like a
nsition as a surgical assistant 2 or 3
E*iys a week. Would prefer Central New
■rsey, but would consider other lo-
tions in New Jersey— New York area
I rite Box No. 98. JMSNJ.
—
RTHOPAEDIC SURGEON— American
iaduate, trained at Downstate Medical
mter, NY; seeks position solo, group or
>spital based. Call during business
iurs 212-819-8706 or write Box No.
>0, JMSNJ.
IYSICIAN — Lifetime NJ resident seeks
I isition in a pediatric group after com-
letion of postgraduate training. Avail-
l*le July 1985. Please contact Charles
meslaw, 8372 Loveridge Court, Rich-
ond, VA 23229.
—
\DIOLOGIST — Board certified, trained
general diagnosis, nuclear medicine,
ecial procedures, CT and ultrasound,
ailable full or part-time. Group prac-
e or hospital based. North or Central
1. Write Box No. 81, JMSNJ.
NEEDED PHYSICIANS — For successful,
well known, walk-in medical office center.
Central NJ. Full and part time, skilled
personable, American trained MDs. Send
CV to E. V. McGinley, MD, 1005 N. Wash-
ington Avenue, Green Brook, NJ 08812.
201-968-8900.
PHYSICIAN — MD for industrial and oc-
cupational health care facility in the
South Jersey resort area Opening No-
vember or December. Duties to include
emergency follow-up/and return to work
treatment, as well as pre-placement and
annual physical exams. Send CV to Box
No. 95, JMSNJ.
WANTED — RADIOLOGY OFFICE
PRACTICE — Board certified radiologist
with nine years hospital based ex-
perience is seeking to buy into or buy out
an active private radiology office practice
in Northern or Central NJ. Write Box No.
71, JMSNJ.
FOR SALE — Active Family and Indus-
trial Practice in Northwestern NJ. Close
to three hospitals. Office consists of large
waiting room, nurses station, three ex-
amining rooms, consultation room, lab-
oratory, x-ray and dark room and lava-
tory. Full basement on 0.6 acre lot. Room
for expansion or another building. Ask-
ing price 8275,000. Call after 8:30 p.m.
201-267-0699.
FOR SALE) — Like new ECG portable
COMPUT-EK with 2 boxes ECG roll
paper, 8900. Telephone days
201 750-8474 or nights 201-647-3793.
FOR SALE — Two Hamilton "premiere"
examining tables. Never used. Mint con-
dition, 8500 each. Call evenings
201-529-3690.
FOR SALE — RECP instrument complete
with accessories, JF-IT, in absolutely new
condition. Used for a short period. Price
quite reasonable and negotiable. Con-
tact; 201-794-8900.
WANTED — Used Medical Office Equip-
ment and Furniture in good condition.
Call 201-287-6357 after 7 p.m. or write
P. O. Box 1048, Edison, NJ 08817.
FOR RENT — Professional office space for
rent. Millbum pnesl^teVs building, 775
square feet, -dg^/srte parking, on bus
route. Call 201-731-1900.
OFFICE FOR SHARE or RENT— New
Brunswick, Highland Park area.
Furnished, 700 square feet. Ample park-
ing, close to the hospital. Rent
8500/month plus utilities. For share
S300/month including utilities. Call
201-846-1661 or 572-7553.
OFFICE TO SHARE — Bergenfield. Cen-
trally located, professional building,
parking, furnished 900 square feet. Five
minutes from hospitals. Call
201-385-8350, Ronny Meier, MD, 297
South Washington Avenue, Bergenfield,
NJ 07621.
OFFICE SPACE — Atlantic City. For rent,
medical office fully equipped and
furnished. 1,300 square feet. Call
609-822-0270.
OFFICE SPACE — Bloomingdale, town of
8000 needs physician, general practice.
New medical office, 990 square feet. Two
examining rooms, x-ray room, dark room,
medical laboratory, consultation room.
Off street parking. H/AC. 201-337-4152
or 201-337-3801.
OFFICE SPACE — Livingston. In Modem
Professional building, convenient to
major highways. Ample parking. Terms
negotiable. Available immediately. Con-
tact 201-992-5588.
OFFICE SUITE — Southern Jersey
(Gloucester Township, Camden County).
For rent in new medical building; 1000
or 2000 square foot suites available.
Located in rapidly growing, highly de-
sirable area near several large hospitals.
Ideal for family practice or specialist.
Building to be completed late 1984. Call
Dr. Ribatsky 609-227-2221.
FOR RENT — West Orange, Office, 850
square feet. Small medical building.
Parking, buses, convenient to Route 280
and hospitals. Call 201-676-3030.
FOR RENT — West New York. Pro-
fessional office, comer location with
parking space on Doctors' row. Close to
hospital and public transporation. Call
201 278 1000 or 201-947-4333.
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' L. 81— NUMBER 10— OCTOBER 1984
NOVEMBER 6, 1984
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JE1
The Journal
of theSmedical
Society of
New Jersey
NOVEMBER 1984
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L. 81— NUMBER 11— NOVEMBER 1984
913
November 1984
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 7 66
Publication Committee
Paul J. Hirsch, M.D., Chairman
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A Schauer, M.D. (Monmouth) Farmingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovacs, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirsch, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica M.D. (1987)
(Middlesex) New Brunswick
Hariy W. Fullerton, Jr., M.D. (1985)
(Salem) Carney’s Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
La Verne Fioretti
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Graphic Artist
Frank Cecala
Executive Director
Vincent A Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia M.D., Chairman (1985) Spring Lake
Alfred A Alessi, M.D. (1986) Hackensack
Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
Henry J. Mineur, M.D. (1986) Cranford
Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood)
Bergen
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock, M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Alan J. Lippman, M.D. (Oncol)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. MeKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A Papa M.D. (Dermatol)
Edwin L. Rothfeld, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer, M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell, M.D. (Radiol)
A Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
The Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) exc
semimonthly in July (13 issues), under direction of the Committee on Publication, by the Medical Society of *
Jersey, Two Princess Road, Lawrenceville, NJ 08648. Printed in East Stroudsburg, PA by the Hughes Print
Co. Whole number of issues 968. Member’s subscription ($10) is included in Society dues. Rates for nonmemtx
$20; outside USA add $7.50 for postage. Single copies, $2. Address communications to The Journal MSNJ, 1
Princess Road, Lawrenceville, NJ 08648, (609) 896-1766. Second-class postage paid at Trenton, NJ, and additio
entry office. Copyright 1984 by the Medical Society of New Jersey.
914
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
-
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PLUS-
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- medical illustrations (including anatomical,
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- medical and biological photography
- video tape productions
Effectively communicating your ideas is our goal.
-V
’201) 766-7747
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Note: If you ’re new to medical practice in N.J. . . .
ifou don’t have to buy commercial
malpractice insurance
AMES S . T ODD , M . D . , Chairman/Board of Directors, Medical In ter-Insurance Exchange of New Jersey
IS you made your decision to establish yourself
n New Jersey, you no doubt heard horror
tories about our professional liability insurance
problems. The legal risks we assume in this
msiness have grown so far out of proportion
hat many commercial underwriters have been
imply unable to cope, resulting in abrupt and
bften untimely suspension of coverage.
As a new practitioner in this State, either
elocating or just beginning your professional
itareer, you have an alternative to commercial
nsurance. The Medical Inter-Insurance
exchange provides an opportunity to build
'our new practice on the most secure footing
possible with long-term peace of mind.
Founded in 1977 at the peak of the
; ‘premium crisis,” the Exchange is a wholly
lloctor-owned cooperative organization
hrough which we insure ourselves for our
VOL. 81— NUMBER 11— NOVEMBER 1984 915
own sake. Membership has grown to two-thirds
of all practicing physicians and surgeons in the
state. Because we’re in it for security — not
for profit — we can provide for ourselves the
absolute best available insurance product for
the money. Every dollar we take in goes toward
.protection (no sales commissions) and every
dollar left over is returned to us — in cash.
You owe it to yourself to know your
options and the practicalities of each. We re
here to help you sort them all out. Call and
talk directly to our Vice President and Director
of Policyholder Services, Bill Reilly, TOLL
FREE (in N.J.) 800-2 57-6288 or
(609) 896-2404 from other areas. We look
forward to hearing from you.
A professional service message from the
Medical Inter-Insurance Exchange of N.J.
Two Princess Road, Lawrenceville NJ 08648
(609) 896-2404
/•s
The Journal
the Medical
Society of
New Jersey
NOVEMBER 198
919 Membership Newsletter
923 Professional Liability Commentary
929 Editorial
93 1 Hospital Governing Boards
Contributions
935 Maternal Deaths in New Jersey — 1982
G.F. Hansen, M.D., and M. Gregory, M.D., Newark
94 1 Ceftriaxone, A Third Generation Cephalosporin
E. S. Johnson, M.D., M. Fedder, M.D., L.G. Smith, M.D., Newark
949 Aortic and Mitral Valve Replacement: Part 1
P.J. Olivieri, M.D., andJ.B. Kostis, M.D., New Brunswick
959 Indium- 1 1 1-Oxine-Labeled Leukocyte Imaging
F. M. Palace, M.D., and R.F. Crystal, M.D., Morristown
967 Pharmacological Basis of Therapeutics:
Insulin-Like Growth Factors
MA Brostrom, Ph.D„ Piscataway
973 Pediatric Briefs
R.H. Rapkin, M.D., F.C. Behrle, M.D., S.C. Sun, M.D., Newark
■MB DOCTORS’ iOTEBOOK^HH^^MBMM
977 Trustees’ Minutes: September 16, 1984
979 UMDNJ Notes, Stanley S. Bergen, Jr., M.D.
979 MSNJ Auxiliary, Grace Gellman
980 AMNJ Report, Robert S. Rigolosi, M.D.
980 Physicians Seeking Location in New Jersey
Mi MSNJ Departments mbi^^^mbhi
983 1984-1985 Committees & Councils
988 Statement of Ownership, Management, and Circulation
991 CME Calendar
995 Letters to the Editor
996 Book Reviews
1005 Obituaries
1 007 Information for Authors
On The Cover: Drs. Olivieri and
New Jersey
Kostis discuss the histoiy of
„ _ j
aortic and mitral stenosis and
aortic and mitral regurgitation
in the first part of their study
on valve replacement, begin-
ning on page 949.
VALVE fiEPI.ACF.MFXT
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERJ
916
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Tablets are prescribed.
Motrin is priced lower than Clinoril, Feldene, or Naprosyn.
The price of Motrin Tablets to pharmacies has been reduced as much as 35%.
Patients taking the average dosage should now pay less for therapy with Motrin Tablets
than for almost any other nonsteroidal anti-inflammatory drug you
prescribe... less, for example, than for Clinoril, Feldene, or Naprosyn. And, of course,
all strengths of Motrin Tablets continue to be available by prescription only.
Please see the following page for a brief summary of prescribing information.
Motrin
buDrolen
Good medicine...good value
TABLETS
mg
© 1984 The Upjohn Company The Upjohn Company 23 Kalamazoo, Michigan 49001
L. 81-NUMBER 1 1— NOVEMBER 1984
917
MofrirP Tablets (ibuprofen)
Contraindications: Anaphylactoid reactions have occurred in individuals hypersensitive to
Motrin Tablets or with the syndrome of nasal polyps, angioedema and bronchospastic reactivity
to aspirin, iodides, or other nonsteroidal anti-inflammatory agents.
Warnings: Peptic ulceration and Gl bleeding, sometimes severe, have been reported. Ulceration,
perforation and bleeding may end fatally. An association has not been established. Use Motrin
Tablets under close supervision in patients with a history of upper gastrointestinal tract disease,
after consulting ADVERSE REACTIONS. In patients with active peptic ulcer and active
rheumatoid arthritis, try nonulcerogemc drugs, such as gold. If Motrin Tablets are used, observe
the patient closely for signs of ulcer perforation or Gl bleeding.
Chronic studies in rats and monkeys have shown mild renal toxicity with papillary edema and
necrosis. Renal papillary necrosis has rarely been shown in humans treated with Motrin Tablets
Precautions: Blurred and/or diminished vision, scotomata, and/or changes in color vision have
been reported. If these develop, discontinue Motrin Tablets and the patient should have an
ophthalmologic examination, including central visual fields and color vision testing.
Fluid retention and edema have been associated with Motrin Tablets; use with caution in patients
with a history of cardiac decompensation or hypertension. In patients with renal impairment,
reduced dosage may be necessary. Prospective studies of Motrin Tablets safety in patients with
chronic renal failure have not been done.
Motrin Tablets can inhibit platelet aggregation and prolong bleeding time. Use with caution in
persons with intrinsic coagulation defects and on anticoagulant therapy.
Patients should report signs or symptoms of gastrointestinal ulceration or bleeding, skin rash,
weight gain, or edema.
Patients on prolonged corticosteroid therapy should have therapy tapered slowly when Motrin
Tablets are added.
The antipyretic, anti-inflammatory activity of Motrin Tablets may mask inflammation and fever.
As with other nonsteroidal anti-inflammatory drugs, borderline elevations of liver tests may
occur in up to 15% of patients. These abnormalities may progress, may remain essentially
unchanged, or may be transient with continued therapy. Meaningful elevations of SGPT or SGOT
(AST) occurred in controlled clinical trials in less than 1% of patients. Severe hepatic reactions,
including jaundice and cases of fatal hepatitis, have been reported with ibuprofen as with other
nonsteroidal anti-inflammatory drugs. If liver disease develops or if systemic manifestations
occur (e.g. eosinophilla, rash, etc.), Motrin should be discontinued.
Drug interactions. Aspirin: used concomitantly may decrease Motrin blood levels.
Coumarm: bleeding has been reported in patients taking Motrin and co'umarin.
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy or by nursing
mothers.
Adverse Reactions: The most frequent type of adverse reaction occurring with Motrin is
gastrointestinal of which one or more occurred in 4% to 16% of the patients.
Incidence Greater than 1 % (but less than 3%)- Probable Causal Relationship
Gastrointestinal: Nausea* epigastric pain,* heartburn,* diarrhea, abdominal distress, nausea
and vomiting, Indigestion, constipation, abdominal cramps or pain, fullness of Gl tract (bloating
and flatulence); Central Nervous System: Dizziness* headache, nervousness; Dermatologic:
Rash* (including maculopapular type), pruritus, Special Senses: Tinnitus; Metabolic/Endocrine:
Decreased appetite; Cardiovascular: Edema, fluid retention (generally responds promptly to
drug discontinuation; see PRECAUTIONS).
Incidence less than 1%-Probable Causal Relationship**
Gastrointestinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastrointestinal
hemorrhage, melena, gastritis, hepatitis, jaundice, abnormal liver function tests; Central
Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, aseptic
meningitis with fever and coma; Dermatologic: Vesiculobullous eruptions, urticaria, erythema
multiforme, Stevens-Johnson syndrome, alopecia; Special Senses: Hearing loss, amblyopia
(blurred and/or diminished vision, scotomata, and/or changes in color vision) (see PRECAU-
TIONS); Hematologic: Neutropenia, agranulocytosis, aplastic anemia, hemolytic anemia (some-
times Coombs positive), thrombocytopenia with or without purpura, eosinophilia, decreases in
hemoglobin and hematocrit; Cardiovascular: Congestive heart failure in patients with marginal
cardiac function, elevated blood pressure, palpitations; Allergic: Syndrome of abdominal pain,
fever, chills, nausea and vomiting; anaphylaxis; bronchospasm (see CONTRAINDICATIONS);
Renal: Acute renal failure in patients with pre-existing significantly impaired renal function,
decreased creatinine clearance, polyuria, azotemia, cystitis, hematuria; Miscellaneous: Dry eyes
and mouth, gingival ulcer, rhinitis.
Incidence less than 1%— Causal Relationship Unknown**
Gastrointestinal: Pancreatitis; Central Nervous System: Paresthesias, hallucinations, dream
abnormalities, pseudotumor cerebri; Dermatologic: Toxic epidermal necrolysis, photoallergic
skin reactions; Special Senses: Conjunctivitis, diplopia, optic neuritis; Hematologic: Bleeding
episodes (e.g., epistaxis, menorrhagia); Metabolic/Endocrine: Gynecomastia, hypoglycemic
reaction; Cardiovascular: Arrhythmias (sinus tachycardia, sinus bradycardia); Allergic: Serum
sickness, lupus erythematosus syndrome, Henoch-Schonlein vasculitis; Renal: Renal papillary
necrosis
‘Reactions occurring in 3% to 9% of patients treated with Motrin. (Those reactions occurring in
less than 3% of the patients are unmarked.)
“Reactions are classified under Probable Causal Relationship ( PCR )" if there has been one
positive rechallenge or if three or more cases occur which might be causally related. Reactions
are classified under "Causal Relationship Unknown" if seven or more events have been reported
but the criteria for PCR have not been met.
Overdosage: In cases of acute overdosage, the stomach should be emptied. The drug is acidic
and excreted in the urine so alkaline diuresis may be beneficial.
Dosage and Administration: Rheumatoid arthritis and osteoarthritis. Suggested dosage is 300,
400, or 600 mg t.i.d. or q.i.d. Do not exceed 2400 mg per day. Mild to moderate pain: 400 mg
every 4 to 6 hours as necessary.
Caution: Federal law prohibits dispensing without prescription. med b-7-s
Motrin is a registered trademark of The Upjohn Manufacturing Company.
Upjohn
The Upjohn Company
Kalamazoo, Michigan 49001
"FIRST OF STATE]
1984 NEW JERSE1
DUCK STAMP PRUT
Federal and state duck stamp prints are amoj
the most desired collections in the U.S. T|
federal program is now 51 years old and is wort™
excess of $80,000.00! A complete set of "firstll
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Mew Jersey is offering their "first". The design is f
a pair of Canvasbacks resting in water. Tc j
Hirata s painting is crisp, clear and classic!
A framed Mew Jersey Duck Stamp Print id
perfect addition to your home or office.
Call collect (609) 983-3771
Ask published and national authority jja
McCaddin for the possible tax advantages in cl
lecting duck stamp prints.
MARLTON
SPORT N
WILDLIFE
GALLERY
(609) 983-3771
Print with two mint stamps $142.50
Executive "color" Remarque Edition w/mints
w/signed w/medallion & rem. $561.50
*Eraming — Two stamp openings $ 80.00
Executive Edition $110.00
Mail Order — Add $7.50 for framed UPS delivery
Add $5.00 for unframed UPS delivery
Signature
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VISA/MC Accepted
| “All matting is to museum specifications with hand-staiil
| Walnut. Medallion editions will be framed in Mahogany \ ti
| gold lip to accent the medallion.
L 4
918
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERfS
Membership
Newsletter
THE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 16
EGALIZE USE OF HEROIN
The AMA is opposed to the proposed House floor
ction on H.R 5290 which would establish a four-year
Togram under which heroin would be made available
o hospitals and hospice pharmacies for terminally ill
ancer patients with intractable pain.
The Association opposes this legislation on three
'rounds: 1 ) Heroin is not necessary since it is no more
ffective than analgesics now available, including
iilaudid HP; 2) Congressional action would establish
n inappropriate precedent by pre-empting the con-
umer protective provisions of the Food, Drug, and
Cosmetic Act that are designed to assure the safety
nd effectiveness of available drug products based on
ound scientific data; and 3) The availability of heroin
ould substantially increase the security problems of
Hospitals and hospices.
lMA LAW SUIT— MEDICARE FEE FREEZE
The AMA filed suit on September 21, 1984, in the
ederal Court, Southern District, Indiana, against the
sderal government and the Secretary of HHS regard-
ing the Medicare fee freeze. The plaintiffs will be the
vMA and the Indiana Medical Society and certain
dedicare beneficiaries. The complaints are as follows:
) The plaintiffs consider the fee freeze unconstitu-
ional; it violates equal protection laws; 2) It effectively
lenies beneficiaries the right to select their own phy-
ician; and 3) It creates unlawful interference in the
ontract rights of physicians and Medicare bene-
iciaries. The AMA also is going to file for a preliminary
njunction against the October deadline for signing,
'hey are claiming the carriers have been unable to
rovide physicians with the information they need on
musual fees. This prevents the physicians from know-
tig at what rate they would be reimbursed if they
igned the agreement.
tMA COMMENTS ON FEDERAL LEGISLATION
tND REGULATIONS
Direct Medicare Reimbursement for Services Per-
orated by Registered Nurse Anesthetists. In a letter
o the House and Senate sponsors of H.R 4683 and
». 1772, authorizing direct Medicare reimbursement
o registered nurse anesthetists, the AMA stated that
the legislation is unnecessary due to a recent modi-
fication in the law authorizing cost-based reimburse-
ment for services performed by nurse anesthetists,
through September 30, 1987, and calling for a study
on Medicare reimbursement methods that will not dis-
courage the use of nurse anesthetists. (Letter to Rep-
resentatives Frank, Jacobs, Waxman and to Senators
Matsunaga, Dole, Durenberger, July 30, 1984.)
Restructuring the Social Security Administration
as an Independent Agency. In a statement to the Ways
and Means Committee, the AMA stated that it believes
that any discussion concerning major reorganization
of the Department of Health and Human Services
should include strong consideration of establishing a
separate U.S. Department of Health. The increasingly
complex nature of medical and other health issues
facing the federal government requires knowledgeable
management and direction. Such direction and man-
agement could be provided if a separate department
is created to focus on these important and sensitive
issues. Until such time as a separate department is
established, the AMA supports H.R 5438, which
elevates the Assistant Secretary for Health to the pos-
ition of Undersecretary of Health. (Statement, Subcom-
mittee on Social Security, House Ways and Means
Committee, August 1, 1984.)
Medicare Program Payment to Health Maintenance
Organizations and Competitive Medical Plans. The
AMA submitted comments to HCFA on a proposed rule
to implement Medicare reimbursement for eligible
health maintenance organizations (HMO) and com-
petitive medical plans (CMP). The Association called
for modifications to the proposed rule to “assure that
beneficiaries will be informed fully of the consequences
of a decision to join or not join an HMO or CMP. We
also are concerned that, while the law authorizing
such organizations to provide health care services re-
quires these organizations to make ‘adequate
provision against the risk of insolvency,’ this proposed
rule does not provide an adequate means of assuring
beneficiaries such protection." In addition, the AMA
commented on the use of the term “physician" in thp
proposed rule, the definition of “emergency services."
and marketing activities allowed for HMOs and CMPs.
(Letter and statement to Health Care Financing Ad-
ministration, August 1, 1984).
OL. 81— NUMBER 11— NOVEMBER 1984
919
PHYSICIANS’ SERVICES COMPONENT OF
CONSUMER PRICE INDEX
The purpose of the physicians’ services component
of the Consumer Price Index (CPI) is to measure
c hanges in physicians' fees paid out of pocket by con-
sumers. This has three important implications: First,
the index does not deal with issues of utilization. If
more people visit physicians as a result of a flu
epidemic, this will have no direct effect on the index.
Second, to the degree that consumers’ use of phy-
sicians' services are covered by third parties, this does
not enter into the data base for construction of the
price index for physician services. Third, given the out-
of-pocket orientation of the survey methodology, the
physicians’ services component systematically under-
represents services delivered by physicians who
specialize in areas for which the great part of charges
are covered by insurance.
AMA STATEMENTS
National Minimum Drinking Age. The AMA sup-
ported a bill, H.R 2441, which would encourage states
to raise their minimum drinking age to 21 by
withholding federal highway funds from states which
do not comply. (Letter to Congressman John E. Porter,
March 1, 1984).
Uniform Minimum Drinking Age Act of 1984. The
AMA commented on S. 2263, a bill which would en-
courage states to raise the minimum drinking age to
21 by reducing federal highway funds for each year
that a state does not comply. While supporting the
purposes of the bill, the AMA urged stronger sanctions
against states which fail to raise the drinking age to
21 years. (Letter to Senator Frank R Lautenberg,
March 16, 1984.)
Airline Medical Kits. The American Medical As-
sociation recommended that the following minimum
diagnostic and therapeutic equipment be required on
all commercial airline flights: a stethoscope, a
sphygmomanometer, airways, splints, tongue blades,
and flashlight. The AMA also called upon the FAA to
conduct a study to determine the number, frequency,
and types of inflight medical emergencies so as to de-
termine the specific need for extended medical kits
and the most appropriate contents for such kits. (Let-
ter to Federal Aviation Administration, January 6,
1984.)
Motor Vehicle Safety. The AMA urged the immedi-
ate implantation of a program requiring passive re-
straints, preferably air cushions, in all new auto-
mobiles. The Association also reaffirmed its support
for child passenger restraint laws, for mandatory seat
belt utilization laws, and for legislative action to
promote the availability of effective seat belts in all
motor vehicles in public use. (Letter to Department of
Transportation, June 22, 1984.)
Dangerous Drug Diversion Control Act of 1984.
The AMA expressed concern over the problem of di-
version of controlled substances to illicit channels and
awareness of the adverse medical, economic, and social
consequences of such activity. The Association also
described a number of measures it has undertaken t
combat illicit drug diversion including the develop
ment of the Prescription Abuse Data Synthesis mode
The AMA supported the general thrust of H.R 4691
a bill that would amend the Controlled Substances A(
and suggested modifications that would strengthe
the bill. In addition, the Association supported ad(
quate funding for the Drug Enforcement Admini:
tration. (Statement to Crime Subcommittee of th
House Judiciary Committee, February 22, 1984.)
Physician Reimbursement Under Medicare. Th
AMA testified on the success and growth of the Med
care program, the growth of health care costs, and hoi
physician reimbursement and beneficiary liability i
determined under Medicare. The testimony discusset
the Association’s support for a one-year freeze in ph]
sicians’ fees and that this voluntaiy freeze was "in lir,
with a one-year freeze of Medicare payments to ph;
sicians as proposed by the President in his recer
budget." The Association opposed proposals to modi
physician reimbursement by basing payments o
diagnosis related groups (DRG), mandating assigi
ment, and through the “participating physician” coi
cept. (Testimony before Senate Special Committee o
Aging, March 16, 1984.)
PROPOSED RULE: MEDICAID ELIGIBILITY
The Division has proposed a rule concerning a p;
tient's financial eligibility for Medicaid. The proposi
indicates that there is no reimbursement for service
performed after termination of eligibility. This stan<
ard conforms to the New Jersey Medicaid law (N.J.S.
30:4D-3i, j) which requires that persons must t
financially eligible for AFDC, SSI, etc. in order to recei\
Medicaid services. This proposal has appeared in tf
New Jersey Register. (August 20, 1984, at 16 NJ!
2219(a)).
DR. COLBURN ELECTED TO NEW JERSEY
GENERAL ASSEMBLY
Harold Colburn, Jr., M.D., a member of our Bui
ington County component, the Board of Directors i
JEMPAC, and a Burlington County Freeholder w
elected by an overwhelming margin to the Assembl
Dr. Colburn will fill the Eighth District Assembly se:
left vacant in July by the death of his Republican cc
league, Robert J. Meyer.
The September special election saw Dr. Colburn,
dermatologist, defeat his Democratic rival, Phil
Haines, by a three to two ratio, capturing 15 of tl
district’s 23 towns. MSNJ’s political action commits
contributed several thousands of dollars to Dr. Cc
bum’s campaign. Dr. Colburn, who will finish the r
maining year of Meyer’s term, will be the only phy*
cian in the state legislature.
FINI
“All the flowers of all the tomorrows are in the seec
of today."
920
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
Nothing else
can take its place.
INDERAL
(PROPRANOLOL HCI)
10 mg 20 mg 40 mg 60 mg 80 mg 90 mg’
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL® (propranolol hydrochloride) Tablets
CLINICAL PHARMACOLOGY
The Beta-Blocker Heart Attack Trial (BHAT) was a National Heart. Lung and Blood Institute-
sponsored multicenter, randomized, double-blind placebo-controlled trial conducted in 31
U S. centers (plus one in Canada) in 3.837 persons without history of severe congestive heart
failure or presence of recent heart failure; certain conduction defects; angina since infarction,
who had survived the acute phase of myocardial infarction. Propranolol was administered at
either 60 or 80 mg t. i d. based on blood levels achieved during an initial trial of 40 mg t.i.d.
Therapy with INDERAL, begun 5-21 days following infarction, was shown to reduce overall
mortality up to 39 months, the longest period of follow-up. This was primarily attributable to a
reduction in cardiovascular mortality. The protective effect of INDERAL was consistent
regardless of age, sex or site of infarction. Compared to placebo, total mortality was reduced
39% at 12 months and 26% over an average follow-up period of 25 months. The Norwegian
Multicenter Trial in which propranolol was administered at 40 mg q.i.d. gave overall results
which support the findings in the BHAT
Although the clinical trials used either t.i.d. or q.i.d. dosing, clinical, pharmacologic and
pharmacokinetic data provide a reasonable basis for concluding that b i d dosing with pro-
pranolol should be adequate in the treatment of post-infarction patients.
CLINICAL: In the BHAT patients on INDERAL were prescribed either 180 mg/day (82% of
patients) or 240 mg/day (18% of patients). Patients were instructed to take the medication 3
times a day at mealtimes. This dosing schedule would result in an overnight dosing interval of
12 to 14 hours which is similar to the dosing interval for a b.i.d. regimen. In addition, blood
samples were drawn at various times and analyzed for propranolol. When the patients were
grouped into tertiles based on the blood levels observed and the mortality in the upper and
lower tertiles were compared, there was no evidence that blood levels affected mortality.
PHARMACOLOGIC; Studies in normal volunteers have shown that a 90 mg b.i d. regimen
maintains beta blockade at, or above, the minimum for 60 mg t.i.d. dosing for 24 hours even
though differences occurred at two time intervals. At 10-12 hours after the first dose of the day,
t.i.d dosing gave more beta blockade than b i d. dosing; at 20-24 hours the trend of the rela-
tionship was reversed. These relationships were similar in direction to those observed for
plasma propranolol levels (see Pharmacokinetics).
PHARMACOKINETIC: A bioavailability study in normal volunteers showed that the blood
levels produced by 180 mg/day given b i d. are below those provided by the same daily dos-
age given t.i d. at 10-12 hours after the first dose of the day but above those of a t.i d. regimen
at 20-24 hours. However, the blood levels produced by b i d. dosing were always equivalent
to or above the minimum for t.i.d. dosing throughout the 24 hours. In addition, the mean AUC
on the fourth day for the b.i.d. regimen was about 17% greater than for the t.i.d. regimen (1,194
vs. 1,024 ng/ml- hr),
CONTRAINDICATIONS
INDERAL is contraindicated in 1) cardiogenic shock, 2) sinus bradycardia and greater than
first degree block, 3) bronchial asthma. 4) congestive heart failure (see WARNINGS) unless
the failure is secondary to a tachyarrhythmia treatable with INDERAL.
WARNINGS
CARDIAC FAILURE: Sympathetic stimulation may be a vital component supporting circula-
tory function in patients with congestive heart failure, and its inhibition by beta blockade may
precipitate more severe failure. Although beta blockers should be avoided in overt conges-
tive heart failure, if necessary they can be used with close follow-up in patients with a history
of failure who are well compensated and are receiving digitalis and diuretics. Beta-
adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks and the patient should be cau-
tioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) PATIENTS WITH
BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA BLOCKERS.
INDERAL (propranolol hydrochloride) should be administered with caution since it may t
bronchodilation produced by endogenous and exogenous catecholamine stimulation of
receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therap
prior to major surgery is controversial. It should be noted, however, that the impaired abil
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesth
and surgical procedures.
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agonists
its effects can be reversed by administration of such agents, e g., dobutamine or isopro-
terenol. However, such patients may be subject to protracted severe hypotension. Diffici
starting and maintaining the heartbeat has also been reported with beta blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent the appea
ance of certain premonitory signs and symptoms (pulse rate and pressure changes) of ;
hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be more dift
to adjust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidism. Tf
fore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoms
hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function te
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bet
reported in which, after propranolol, the tachycardia was replaced by a severe bradyca
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 mg
propranolol
PRECAUTIONS
General: Propranolol should be used with caution in patients with impaired hepatic or re
function. INDERAL is not indicated for the treatment of hypertensive emergencies.
Beta-adrenoreceptor blockade can cause reduction of intraocular pressure. Patients
should be told that INDERAL may interfere with the glaucoma screening test. Withdraws
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dise
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re
pine should be closely observed if INDERAL is administered The added catecholamine
blocking action may produce an excessive reduction of resting sympathetic nervous ac
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or ortf
static hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals h
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studie
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sir
cant drug-induced toxicity. There were no drug-related tumorigenic effects at any of the
age levels. Reproductive studies in animals did not show any impairment of fertility that
attributable to the drug.
Pregnancy Pregnancy Category C. INDERAL has been shown to be embryotoxic in <
studies at doses about 10 times greater than the maximum recommended human dose.
There are no adequate and well-controlled studies in pregnant women. INDERAL she
be used during pregnancy only if the potential benefit justifies the potential risk to the te
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercised v
INDERAL is administered to a nursing woman.
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS
Most adverse effects have been mild and transient and have rarely required the withdrs
therapy
Cardiovascular bradycardia; congestive heart failure; intensification of A V block, hy|
sion; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency usually of
Raynaud type
Central Nervous System: Lightheadedness; mental depression manifested by msom
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; vi
disturbances; hallucinations; an acute reversible syndrome characterized by disorient;
for time and place, short-term memory loss, emotional lability, slightly clouded sensoriu
and decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarrhe
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with a
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has been
reported.
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impc
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reactiq
involving the skin, serous membranes and conjunctivae reported for a beta blocker (pr
lol) have not been associated with propranolol.
"The appearance of INDERAL tablets is a registered trademark of Ayerst Laboratorie:
8965/28
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
’ROFESSIONAL LIABILITY
Commentary*
Malpractice: Two
Points of View
Is the problem medical malpractice
claims or medical malpractice ?
Attention needs to be focused on the
incidence of actual malpractice.
Much attention has been given re-
cently to allegations that soar-
ing health care costs are the re-
lit of increasing medical malpractice suits. The facts
cmonstrate that this is not correct.
For example, in 1980, the total cost of health care
!i Pennsylvania was $10.7 billion; the total amount
lid out in 1980 as a result of malpractice claims was
mere 4/10 of 1 percent of that figure.
Regarding the costs of malpractice insurance in
mnsylvania, the average physician spends 3.5 per-
mit of his gross income on medical malpractice in-
irance, a tax-deductible business expense— exactly
ie national average. It is very likely that most motor-
ts pay about as large a percentage of their gross
icomes for automobile insurance that is not tax de-
jctible. Of course, some physicians whose specialties
volve especially high risks to patients pay higher
^rcentages of their gross for medical malpractice in-
trance; however these specialists also enjoy net in-
imes substantially higher than the average phy-
leian.
Legislative efforts to reduce or eliminate needed
>mpensation for the victims of medical malpractice
ill not cut costs. Someone will pay for the harm done.
Such proposals simply would shift this heavy cost
trden from the wrongdoer who caused it, onto the
icks of the victims, their families, and the taxpaying
tblic.
Instead of the wrongdoer paying for the harm out
liability insurance for medical malpractice or other-
wise, the victim and the victim’s family would pay out
of their savings and other assets, including their
health insurance (group and private), their sick leave,
and disability insurance, and ultimately the taxpayer
will pay in many cases through Medicare, Medicaid,
medical assistance, and public assistance of all types.
Allegations of enormous costs attributable to so-
called “defensive” medicine cannot be verified or
substantiated. In fact, performing procedures solely to
protect the doctor from a possible lawsuit without any
medical need is not only unethical but also an assault
and batteiy on the patient. “Defensive” medicine is
nothing more than an emotional and pejorative term
used by doctors to describe either the grudging prac-
tice of more careful medicine which means better, safer
health care for patients, or a rationalization to excuse
the profitable over-utilization of medical resources.
Further, the potential for liability prevents many
deaths and countless serious injuries every year which
would cost the health care system far more than the
total cost of all malpractice claim payments.
Moreover, there is no justification for granting phy-
sicians special privileges and immunities not held by
any other class of citizens. Doctors should be respon-
sible for their conduct like anyone else.
Only 1 in 10 incidents of malpractice results in a
claim being made. Less than half of these claims result
in compensation from medical malpractice insurance.
In fact, no more than 1 out of 25 incidents of malprac-
tice result in the victim receiving compensation
through malpractice insurance.
The problem is not medical malpractice claims, it is
medical malpractice. Claims and litigation are merely
the symptoms. Instead of focusing our efforts on shift-
ing the cost of medical malpractice from the wrongdoer
who caused the harm onto the backs of the victims and
the taxpaying public, attention should be focused on
reducing the incidence of actual malpractice. Such ef-
forts not only would result in real savings, but would
prevent much human misery.
The relatively small number of incompetent and im-
paired physicians who cause a disproportionate share
of malpractice claims should be removed from the
practice of medicine. According to Pennsylvania Medi-
cal Society statistics, at least 10 percent of phy-
sicians are impaired by drug or alcohol abuse at some-
time in their careers.
According to recent testimony in front of the U.S.
Senate Committee on Aging, chaired by Senator John
Heinz (R, PA), Pennsylvania is one of fewer than ten
states without a law requiring hospitals, peer review
and professional organizations, insurance companies,
and others who know the names of incompetent and
impaired physicians to report those names to the State
Licensing Board so that appropriate action can be
taken.
Also needed is risk management legislation to iden-
tify frequently recurring types of malpractice in order
to develop standardized training and procedures to
prevent future instances of similar malpractice.
*This item from the Department of Professional Liability Con-
trol, MSNJ, was prepared by James E. George, M.D., J.D., and
A Ronald Rouse, who are respectively. Director of the Depart-
ment and Director of Special Projects.
)L. 81— NUMBER 11— NOVEMBER 1984
923
The Pennsylvania Trial Lawyers Association is eager
to work with other concerned organizations to help
develop a comprehensive program for health care cost
containment and quality assurance.
James F. Mundy
Chairman, Pennsylvania Trial Lawyers Association
Task Force on Health Care Cost
(The Philadelphia Inquirer , July 18, 1984)
REPLY: LAWSUITS RAISE HEALTH CARE COSTS
The article by James F. Mundy, “Malpractice Suits:
A Medical Problem,” included a number of statements
that are subject to question.
The first of these is that increasing numbers of
medical malpractice suits are not a factor in soaring
health care costs and that the cost of malpractice in-
surance is proportionately no greater than what most
car owners pay for insurance.
While Mr. Mundy quotes an average national figure
of 3.5 percent of a physician’s gross income as the cost
of medical liability insurance, that figure, even if ac-
cepted as accurate, does not reflect the true one of
many physicians in the Philadelphia area who are
practicing the more complicated and risk-associated
specialties, such as general surgery and surgical
specialties.
A more realistic figure for this group is 15 percent
to 20 percent of gross income, such gross income being
well below what many people may believe these phy-
sicians earn. There are many surgical specialists who
may be grossing $ 100,000 and who are paying $33,000
or more, in addition to all other expenses necessary to
maintain a practice.
Mr. Mundy is in error when he states that “defensive
medicine” is illusory and does not play a part in the
increasing cost of medical care. Testimony before the
House Ways and Means Committee on June 28 set the
cost of defensive medicine at $15 billion or more a year,
and these are only incurred to protect the physician
from allegations of malpractice when a medical result
is less than optimal. These defensive-measure figures
are real, not imagined.
Mr. Mundy suggests that getting rid of the incomp
tent physicians would solve the problem, suggestir
that there would be very few malpractice claims. T1
incompetent physician is generally not the one again
whom claims are made. Most claims are against tl
leaders in the medical community, those to whom ai;
physician would gladly go if he himself needed medic
care.
Errors in medical care do occur, and when a patiei
is harmed there should be adequate compensatio
This is why the physicians carry professional liabilii
insurance.
However, while the aggregate insurance fund s
aside is more than adequate, less than 35 perce
reaches the injured parties. The remainder is gobbl<
up by the cost of litigation, the beneficiaries being tl
plaintiff, and defense bars.
If the plaintiff s bar is truly concerned with the wi
fare of their clients, why is it so opposed to a limit <
the fees that they would be paid? The schedi
proposed by the Medical Society adequately would r
imburse a lawyer for his efforts, without allowing hi
a windfall. At present, in may cases, the patient’s la'!
yer receives much more than his client. The insuran
fund has not been set up as “slush” fund for lawyei
Jerry Zaslow, M.D., J.
Preside]
Philadelphia County Medical Socie
( The Philadelphia Inquirer, August 8, 198
FOOTNOTE
The problem of outsized awards in medical malprgj
tice eases appears to be getting worse, according to
study by the Insurance Information Institute. La
year, judgments against physicians and hospitals
California totaled $31.8 million, compared with $1E
million the previous year. And the average award
$649,210 was more than twice 1982’s figure 1
$257,222. On the other hand, the number of verdic;
in the plaintiffs favor dropped 18 percent. (Media
Economics, July 23, 1984)
924 THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
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YOUR MfH/eOrtxXnl
Irnmnct * agent
On nitrates,
but angina still
strflkes...
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
926
After a nitrate,
add ISOPTIN
(verapamil HCl/Knoll)
To protect your patients, as well as their quality of life,
add isoptln Instead of a beta blocker.
First, Isoptin not only reduces myocardial oxygen demand
by reducing peripheral resistance, but also increases coro-
nary perfusion by preventing coronary vasospasm and
dilating coronary arteries — both normal and stenotic.
These are antianginal actions that no beta blocker
can provide.
Second, Isoptin spares patients the
beta-blocker side effects that may
compromise the quality of life.
With Isoptin, fatigue, bradycardia and mental
depression are rare. Unlike beta blockers,
Isoptin can safely be given to patients with
asthma, COPD, diabetes or peripheral
vascular disease. Serious adverse
reactions with Isoptin are rare
at recommended doses; the
single most common side
effect is constipation (6.3%).
Cardiovascular contra-
indications to the use of
Isoptin are similar to those
of beta blockers: severe
left ventricular dysfunction,
hypotension (systolic pres-
sure <90 mm Hg) or cardio-
genic shock, sick sinus syndrome
(if no artificial pacemaker is present)
and second- or third-degree AV block.
So, the next time a nitrate is not enough, add
Isoptin . . .for more comprehensive antianginal
protection without side effects which may
cramp an active life style.
ISOPTIN. Added
antianginal protection
without beta-blocker
side effects.
Please see brief summary on following page.
L. 81 -NUMBER 11— NOVEMBER 1984
ISOPTIN TABLETS
(verapamil HCl/Knoll)
80 mg and 120 mg
Contraindications: Severe left ventricular dysfunction (see Warn-
ings), hypotension (systolic pressure <90 mm Hg) or cardiogenic
shock, sick sinus syndrome (if no pacemaker is present), 2nd- or 3rd-
degree AV block. Warnings: ISOPTIN should be avoided in patients
with severe left ventricular dysfunction (e.g., ejection fraction <30%)
or moderate to severe symptoms of cardiac failure. Control milder
heart failure with optimum digitalization and/or diuretics before
ISOPTIN is used. ISOPTIN may occasionally produce hypotension
(usually asymptomatic, orthostatic, mild, and controlled by decrease
in ISOPTIN dose). Occasional elevations of liver enzymes have been
reported; patients receiving ISOPTIN should have liver enzymes moni-
tored periodically. Patients with atrial flutter/fibrillation and an acces-
sory AV pathway (e.g., W-P-W or L-G-L syndromes) may develop a
very rapid ventricular response after receiving ISOPTIN (or digitalis).
Treatment is usually D.C. -cardioversion. AV block may occur (3rd
degree, 0.8%). Development of marked Ist-degree block or progres-
sion to 2nd- or 3rd-degree block requires reduction in dosage or,
rarely, discontinuation and institution of appropriate therapy. Sinus
bradycardia, 2nd-degree AV block, sinus arrest, pulmonary edema,
and/or severe hypotension were seen in some critically ill patients
with hypertrophic cardiomyopathy who were treated with ISOPTIN.
Precautions: ISOPTIN should be given cautiously to patients with
impaired hepatic function (in severe dysfunction use about 30% of
the normal dose) or impaired renal function, and patients should be
monitored for abnormal prolongation of the PR interval or other
signs of overdosage. Studies in a small number of patients suggest
that concomitant use of ISOPTIN and beta blockers may be beneficial
in patients with chronic stable angina. Combined therapy can also
have adverse effects on cardiac function. Therefore, until further
studies are completed, ISOPTIN should be used alone, if possible If
combined therapy is used, patients should be monitored closely.
Combined therapy with ISOPTIN and propranolol should usually be
avoided in patients with AV conduction abnormalities and/or de-
pressed left ventricular function or in patients who have also recently
received methyldopa. Chronic ISOPTIN treatment increases serum
digoxin levels by 50% to 70% during the first week of therapy, which
can result in digitalis toxicity. The digoxin dose should be reduced
when ISOPTIN is given, and the patient carefully monitored. ISOPTIN
may have an additive hypotensive effect in patients receiving blood-
pressure-lowering agents. Disopyramide should not be given within
48 hours before or 24 hours after ISOPTIN administration. Until fur-
ther data are obtained, combined ISOPTIN and quimdine therapy in
patients with hypertrophic cardiomyopathy should probably be
avoided, since significant hypotension may result. Adequate animal
carcinogenicity studies have not been performed. One study in rats
did not suggest a tumorigenic potential, and verapamil was not
mutagenic in the Ames test. Pregnancy Category C: There are no
adequate and well-controlled studies in pregnant women. This drug
should be used during pregnancy, labor, and delivery only if clearly
needed. It is not known whether verapamil is excreted in breast milk;
therefore, nursing should be discontinued during ISOPTIN use.
Adverse Reactions: Hypotension (2.9%), peripheral edema (1.7%),
AV block: 3rd degree (0.8%), bradycardia: HR<50/min (1 .1 %), CHF
or pulmonary edema (0.9%), dizziness (3.6%), headache (1.8%),
fatigue (1.1%), constipation (6.3%), nausea (1.6%). The following
reactions, reported in less than 0.5%, occurred under circumstances
where a causal relationship is not certain: confusion, paresthesia,
insomnia, somnolence, equilibrium disorders, blurred vision, syncope,
muscle cramps, shakiness, claudication, hair loss, maculae, and spotty
menstruation. Overall continuation rate of 94.5% in 1,166 patients.
How Supplied: ISOPTIN (verapamil HCI) is supplied in 80 mg and
120 mg sugar-coated tablets. July 1982 2068
O. KNOLL PHARMACEUTICAL COMPANY
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928
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
*
Editorial
I Did Not Sign
I did not sign the Medicare contract con-
cerning the fee freeze and I have no in-
tention to do so.
Like all physicians, I received a
Medicare contract. 1 read it
carefully, but I did not sign and
have no intention to do so.
I have many patients who have a card entitling them
> have health care services reimbursed by the federal
jvemment to which they have paid taxes for many
;ars. They are not Medicare patients; they are people
ho have an insurance card! Among them are individ-
als who are barely surviving economically, some who
re millionaires, and many who are very comfortable
nancially.
The Medicare contract and the law (the Deficit Re-
action Act of 1984, P.L. 98-369), on which the con-
act was based, contains some promises and some
meats. I made a careful analysis of my practice and
(included that the fee freeze followed by P.O. 98-369
;ill reduce my practice income from 30 to 50 percent,
ad will necessitate a marked reduction of my office
:aff (registered nurse, insurance clerk-bookkeeper, re-
?ptionist, part-time physician, and part-time dieti-
i an). I also concluded that I could not function on a
0L. 81— NUMBER 11— NOVEMBER 1984
60- to 80-hour week with less help and such a drastic
reduction in practice income.
Aside from the above, I did not sign as a matter of
principle:
1 . The law is unfair and discriminatory. There is no
profession in America whose salaries and income are
frozen. The President, House of Representatives, and
Senate have not frozen their salaries, despite the fact
that many of them are millionaires. Government em-
ployees have not had their wages frozen. The lawyers
who negotiated a $180 million settlement for alleged
victims of the herbicide Agent Orange asked for up to
$26 million in legal fees.
2. I do not advertise. Being old-fashioned, I feel it
lowers my profession to advertise in newspapers and
other media The privilege of having my name on a
“participating physicians” list is no carrot and having
my name on a “nonparticipating physicians” list is no
threat.
3. The law is a threat to patients’ freedom of choice.
My patients select me as their physician and keep me
as their physician because they choose to do so. If I
meet their needs, they stay with me. If I do not they
select another physician.
4. They are wrong again — the government planners
were wrong when they estimated the cost of Medicare
and Medicaid. They will be wrong again for the “sav-
ings” will be an atom in the bucket known as the
national deficit.
Each of us has to make his or her own decision. I
applaud the AMA for initiating a lawsuit against
Margaret Heckler, Secretary of the Department of
Health and Human Services. The complaint argues
that the law violates the rights of Medicare
beneficiaries and of physicians in several ways:
1. It is possible that patients would lose their right
(granted by the Medicare law) to choose the physician
because that physician would be economically unable
to continue caring for them for the amount of money
to be paid by Medicare.
2. At the end of the freeze period. Medicare’s 80
percent of an approved amount will be less for patients
of nonparticipating physicians for the same services.
This is a violation of the Medicare law and of the Fifth
Amendment.
3. The freeze, which prohibits nonparticipating
physicians from increasing their charges to Medicare
patients — even when those patients are able and per-
fectly willing to pay more — forbids physicians from
freely making contracts with patients. Such restric-
tions do not exist against any other part of our society,
or against any other element of the economy.
I intend to treat my patients, who are recipients of
Medicare benefits and who select me as their phy-
sician, to the best of my ability. Like all physicians, I
will accept the insurance payment for those who can-
not afford to pay my usual fee. I expect most New Jersey
physicians will do the same.
It seems obvious to me that this is the moment for
American physicians to take a strong stand together.
As Harry Schwartz, Ph.D., the nationally known
journalist, editor, and critic, said, “The American Medi-
cal Association is the only game in town," when it
comes to protecting physicians’ rights. A.K.
929
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110SPITAL GOVERNING
BOARDS*
Fiduciary Responsibility
Vincent A. Maressa, j.d.
Members of a hospital governing board
S are fiduciaries of the hospital
corporation. This relationship is a
| special one— ethically and legally.
Ij
Members of a hospital governing
board are fiduciaries of the hos-
pital corporation, and of the
lareholders or members of the corporation. This rela-
onship is a special one, both ethically and legally. It
cans that the interests of the individual must be
f’bordinated to that of the institution. Board mem-
rs may not take secret profits from the hospital or
Tipete with it. Board members must exercise reason-
le care, skill, and diligence in the discharge of their
ties.
The requirements of proper fiduciary conduct pres-
t serious questions for physicians and lay members
ving on hospital governing boards. There is no per
f rule that one cannot render this service objectively
id to the full benefit of the hospital corporation while
ivancing his own interests. It does mean, however,
Iiat physicians who serve on a governing board should
tat structure their private practices to have a substan-
al adverse impact on the hospital’s operation. Busi-
essmen on the board may contract with the hospital.
t hose contracts, however, should be at arm’s-length
pd carefully reviewed to assure absolute fairness to
ie hospital. Attorneys serving as board members
"lould not be acting as legal counsel to the board or
) the hospital administration. Their representation of
either should be only on a limited and ad hoc basis,
which has undergone careful scrutiny.
Post, Peters, and Stahl point out in their recent pub-
lication, The Laws of Medical Practice in Penn-
sylvania and New Jersey, that according to the Penn-
sylvania administrative code, members of a governing
body may not maintain substantial, personal, or busi-
ness interests, which conflict with those of the hospi-
tal. All such members must execute a conflict of
interest statement. The code further proscribes certain
forms of self-dealing.
In New Jersey, we do not have specific statutoiy or
regulatory laws on this topic. Our case law declares
simply that a fiduciaiy duty exists not only to the
hospital, but to the general public it serves. Breach of
this duty can lead to personal liability for acts carried
out in the name of the hospital.
Every governing body should request its legal coun-
sel to present an opinion and discussion of applicable
conflict of interest and fiduciary law and conduct so
that governing board members may properly serve the
hospital entity.
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal, MSNJ; Vincent A. Maressa, J..D.,
Executive Director, MSNJ; and James E. George, M.D., J.D.,
Director of Professional Liability. MSNJ.
OL. 81— NUMBER 11— NOVEMBER 1984
931
DOCUMENTED
IN THE SLEEP LABORATORY
1-5
• • •
DALMANE (flurazepam HCI/RocI
PROVIDES ALL THESE BENEFIT
FOR RESTFUL SLEEf
• Rapid sleep onset1!
"ore total time'asfe
Undiminished efficacy for at leat
28 consecutive nights
Patients usually awake rested an
refreshed
• Avoids causing early awakenings c
rebound insomnia after discontinuation2 510'
Copyright fy84 hv Roche Products Inc All rights reserved.
I 1
m
JJSE THERE IS NO
■"i/rsm - , _ _«
15-MG/30-MG CAPSULES
Caution patients about driving, operating hazardous machinery
y or drinking
alcohol during therapy. Limit dose to 15 mg in elderly or debilitated patients,
Contraindicated during pregnancy.
See next page for references and su^nmauof product information
DALMANE
flurozepom HCI/Poche
References: 1. Kales J et at. Clin Pharmacol Ther
12 691-697. Jul-Aug 1971 2. Kales A el al: Clin Phar-
macol Ther 18: 356-363, Sep 1975. 3. Kales A et al:
Clin Pharmacol Ther 19: 576-583, May 1976 4. Kales A
et at Clin Pharmacol Ther 32:781 -788, Dec 1982.
5. Frost JD Jr, DeLucchi MR J Am Geriatr Soc
27 541-546, Dec 1979 6. Kales A, Kales JD J Clin
Pharmacol 3 140-150, Apr 1983 7. Greenblatt DJ.
Allen MD, Shader Rl: Clin Pharmacol Ther 21 355-361,
Mar 1977. 8. Zimmerman AM Curr Ther Res
13 18-22, Jan 1971 9. Amrein R et at Drugs Exp Clin
Res 9(1) 85-99, 1983 10. Monti JM Methods Find Exp
Clin Pharmacol 3 303-326 May 1981 11. Greenblatt DJ
et al: Sleep 5(Suppl 1) S18-S27, 1982 12. Kales A
et al Pharmacology 26 121-137,1983
DALMANE" @
flurazepam HCI/Roche
Before prescribing, please consult complete
product information, a summary of which follows:
Indications: Effective in all types of insomnia charac-
terized by difficulty in falling asleep, freguent nocturnal
awakenings and/or early morning awakening, in
patients with recurring insomnia or poor sleeping
habits, in acute or chronic medical situations reguiring
restful sleep Ob|ective sleep laboratory data have
shown effectiveness for at least 28 consecutive nights
of administration. Since insomnia is often transient
and intermittent, prolonged administration is generally
not necessary or recommended Repeated therapy
should only be undertaken with appropriate patient
evaluation
Contraindications: Known hypersensitivity to fluraze-
pam HCI, pregnancy Benzodiazepines may cause
fetal damage when administered during pregnancy.
Several studies suggest an increased risk of congeni-
tal malformations associated with benzodiazepine use
during the first trimester Warn patients of the potential
risks to the fetus should the possibility of becoming
pregnant exist while receiving flurazepam Instruct
patient to discontinue drug prior to becoming preg-
nant Consider the possibility of pregnancy prior to
instituting therapy
Warnings: Caution patients about possible combined
effects with alcohol and other CNS depressants An
additive effect may occur if alcohol is consumed the
day following use for nighttime sedation This potential
may exist for several days following discontinuation
Caution against hazardous occupations requiring
complete mental alertness (e g , operating machinery,
driving). Potential impairment of performance of such
activities may occur the day following ingestion Not
recommended for use in persons under 15 years of
age. Though physical and psychological dependence
have not been reported on recommended doses,
abrupt discontinuation should be avoided with gradual
tapering of dosage for those patients on medication
for a prolonged period of time Use caution in adminis-
tering to addiction-prone individuals or those who
might increase dosage
Precautions: In elderly and debilitated patients, it is
recommended that the dosage be limited to 15 mg to
reduce risk of oversedation, dizziness, confusion and
or ataxia Consider potential additive effects with other
hypnotics or CNS depressants Employ usual precau-
tions in severely depressed patients, or in those with
latent depression or suicidal tendencies, or in those
with impaired renal or hepatic function
Adverse Reactions: Dizziness, drowsiness, light-
headedness, staggering, ataxia and falling have
occurred, particularly in elderly or debilitated patients
Severe sedation, lethargy, disorientation and coma,
probably indicative of drug intolerance or overdosage,
have been reported Also reported headache, heart-
burn, upset stomach, nausea, vomiting, diarrhea,
constipation, Gl pain, nervousness, talkativeness,
apprehension, irritability, weakness, palpitations, chest
pains, body and joint pains and GU complaints There
have also been rare occurrences of leukopenia, gran-
ulocytopenia, sweating, flushes, difficulty in focusing,
blurred vision, burning eyes, faintness, hypotension,
shortness of breath, pruritus, skin rash, dry mouth,
bitter taste, excessive salivation, anorexia, euphoria,
depression, slurred speech, confusion, restlessness,
hallucinations, and elevated SGOT, SGPT, total and
direct bilirubins, and alkaline phosphatase: and para-
doxical reactions, eg. excitement, stimulation and
hyperactivity
Dosage: Individualize for maximum beneficial effect.
Adults: 30 mg usual dosage; 15 mg may suffice in
some patients. Elderly or debilitated patients: 15 mg
recommended initially until response is determined
Supplied: Capsules containing 15 mg or 30 mg
flurazepam HCI.
Roche Products Inc
Manati, Puerto Rico 00701
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934
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS '
Maternal Deaths In
Vew Jersey— 1982*
Gerard F. Hansen, m.d., m.p.h., Newark**
Margaret Gregory, m.d., faa.p., trenton**
Twenty-four deaths of pregnant women were reported in
New Jersey in 1982. Obstetrical hemorrhage was a factor in
three of the nine potentially preventable deaths. Complications
following postpartum sterilization were associated with
six maternal deaths.
The Subcommittee on Maternal
Mortality, a subdivision of the
Committee of Maternal and In-
it Welfare, is charged with investigating all maternal
aths in New Jersey on a yearly basis. This task is
complished with the help and cooperation of the
atemal and Child Health Program of the State De-
rtment of Health. Health care facilities are required
report maternal deaths and to forward to the State
•partment of Health a copy of the available records,
aterials then are forwarded to the chairperson of the
beommittee for review. The chairperson assigns
ch case or cases to a member of the subcommittee.
ie committee member prepares a brief outline of
ch case and it is presented at the annual meeting
the subcommittee. A consensus regarding prevent-
ility is reached and a report is issued and published
The Journal. The focus of the article is educational
d serves to point out areas of care that can be im-
oved.
SSULTS
There were 94,965 live births in New Jersey in 1982;
deaths of pregnant women were reported and
csented to the committee for evaluation.1 This is an
.rease over the 18 deaths reported in 1981, 2 but this
iy be due to increased surveillance and a question
the revised death certificate which asks if the per-
p was pregnant at the time of death.
Abdominal delivery, multiparity, and being
nonwhite, continue to be factors that increase the risk
of maternal death. Prenatal care was deemed adequate
in only 46 percent of the cases. Six of the 20 maternal
deaths did not have a postmortem examination.
A maternal death is defined as the death of a woman
within 90 days of termination of pregnancy regardless
of duration or site of pregnancy, from any cause related
to or aggravated by the pregnancy or its management,
but not from accidental or incidental causes.3 The
World Health Organization fWHO) uses 42 days of ter-
mination of pregnancy in its statistics. New Jersey
currently uses the WHO definition.
A nonmaternal death is the death of a woman who
was pregnant but whose demise was not relative to the
pregnancy or its management. A bombing, an auto
accident, a fire, and a drug overdose each caused one
nonmaternal death. Such catastrophes remind us that
This article is the result of the work of (he members of the
Subcommittee on Maternal Mortality and the State Depart
ment of Health: James P. Thompson, M.D., Chairman; Jerald
R Cureton, M.D.; Joseph DeStefano, M.D.; Eugene M.
Graziano, M.D.; Margaret Gregory, M.D.: William Hartko. M.D.;
Michael Kreitzer, M.D.; Robert Malatesta, M.D.; Thomas A.
Noone, M.D.; Joseph Saladino, M.D.; and Leah Ziskin. M.D.
**Dr. Hansen is Associate Professor of Clinical Obstetrics and
Gynecology and Director of the Obstetrical and Gynecology
Clinic at the UMDNJ New Jersey Medical School. Dr. Gregory
is Coordinator. Maternal and Child Health Program New Jer-
sey State Department of Health. Correspondence may be ad-
dressed to the Department of Ob-Gyn, UMDNJ-New Jersey
Medical School, 100 Bergen Street, Newark, NJ 07103.
L. 81— NUMBER 11— NOVEMBER 1984
935
TABLE 1
Classification and Mortality Rates
Live Births*
94,965
Maternal Deaths
24
Nonmatemal
4
Indirect
8
Direct
12
Rate (indirect only)
8.4/100,000 live births
Rate (direct only)
12.6/100,000 live births
Rate (all causes)
21.0/100,000 live births
*Live births are events in New Jersey hospitals. Total
births to New Jersey residents in 1983 exceeded this total
because some women delivered out of state.
TABLE
2
Characteristics of Maternal Deaths by Race, Age,
and Prenatal
Care*
Race
Number
Percent
White
8
40
Other
12
60
Age
Less than 20
1
5
20 to 34
13
65
35 to 39
3
15
Greater than 40
3
15
Prenatal Care
None
2
10
Inadequate
1
5
Unknown
8
40
Adequate
8
40
Excluded (ectopic)
1
5
‘Nonmatemal deaths excluded
accidental injuries too often occur to pregnant women.
Drugs still remain a problem in our society as
evidenced by one death of a pregnant woman. The
above deaths should be preventable and were due to
conditions in our society that must be addressed.
An indirect maternal death is the death of a preg-
nant woman resulting from previously existing disease
or a disease that develops during pregnancy, labor, or
the puerperium which is not directly due to obstetrical
causes, but is aggravated by the physiological effects
of pregnancy. There were eight such deaths, six of
which were felt to be nonpreventable by our present
medical standards of care.
A potentially preventable death was due to
cardiomegaly in a patient who died one day after a
postpartum sterilization. The patient had a history of
alcohol and drug abuse and should have been evalu-
ated medically before an elective procedure such as a
tubal ligation was performed. A second patient died of
paralytic ileus following a postpartum sterilization. It
was felt that too little attention was paid to the patient
postoperatively.
Three of the six indirect nonpreventable deaths were
due to diseases of the heart (rheumatic heart disease,
aortic valve disease, and cardiomyopathy). One ease of
gangrene of the small bowel following repeat cesarean
section with tubal ligation was felt to be nonprevent-
TABLE 3
Parity and Duration of Pregnancy
Parity
Number
Percent
0
2
10
1 to 3
14
70
4 to 6
3
15
Unknown
1
5
Gestational Age
Less than 20 weeks
2
10
20 to 28
3
15
28 to 40
8
40
Over 40
6
30
Unknown
1
5
TABLE 4
Classification
and Preventability
Nonmatemal
Maternal
Indirect
8
Nonpreventable
6
Preventable
2
Direct
12
Nonpreventable
4
Preventable
8
Physician factor
8
Patient factor
1*
*In one death physician and patient shared preventabili
able. The deaths of one patient with cystic fibrosis a I
another with a rare hemolytic anemia were jud^l
nonpreventable by present day standards of care. :
A direct maternal death is the death of a pregntN
woman usually from complications of the pregnar .
labor, puerperium, intercessions, omissions, incorrt!
treatment, or a chain of events resulting from any!
these complications.
Two cases of amniotic fluid embolus were found!
be nonpreventable as in each case there had been >ij
preceding event (such as injudicious use of Pitocii®
that could have contributed to the events. An auto]j|
in one instance established the cause of death to h;jl
been amniotic fluid embolism and not eclampsia it
was diagnosed clinically. The value of postmort M
examination in this ease is obvious. A patient witll
ruptured ectopic pregnancy was dead on arrival ajl
hospital; she had not sought prenatal care.
Of the eight direct maternal deaths that were feltl
be potentially preventable, three deaths were due )j
postpartum hemorrhage. In two of these cases, placnl
ta previa and cesarean section were involved and the
was a failure to adequately and quickly replace bid
loss resulting in shock and development of coagulati;$
disorders. The third patient died as a result of hem
rhage due to a ruptured uterus when an internal vj
sion for a dead infant was attempted. In this instanj
the woman was obese and presented herself at fl
hospital with a history of contractions for one dayt
fetal arm had prolapsed through the cervix. BecaD
of the obesity, a version was attempted and the uteijf
936
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
TABLE 5
Causes of Death
No. Total
I. NonmatemsJ 4
Auto accident 1
Bombing 1
Drug overdose 1
Fire 1
II. Maternal
A. Indirect 8
1. Nonpreventable
Hemolytic anemia 1
Rheumatic heart disease 1
Cystic fibrosis 1
Gangrene of the small bowel 1
Aortic valve disease 1
Subarachnoid hemorrhage 1
2. Preventable
Paralytic ileus post-tubal litigation 1
Cardiac failure associated with tubal ligation 1
B. Direct 12
1. Nonpreventable
Amniotic fluid embolus 2
Ruptured ectopic pregnancy 1
2. Preventable
Amniotic fluid embolus 1
Anesthesia 1
Postpartum hemorrhage 3
Self-induced abortion 1
Adult respiratory distress syndrome secondary to sepsis 1
Septic pulmonary embolus after postpartum tubal ligation 1
Ileus secondary to torsion of greater omentum 1
uterine segment was not diagnosed prior to post-
mortem examination. A patient in the hospital with a
history of ruptured membranes at 20 weeks’ gestation,
not confirmed, attempted a self-abortion with a clothes
hanger. Autopsy revealed a lower segment uterine
laceration with a pneumocardium of 300 ce of air in
the right side of the heart. An awareness of the desper-
ation of this woman might have prevented this
tragedy. It is important to remember that this type of
situation might recur if abortions once more are made
illegal.
One patient had cardiac failure secondary to inabili-
ty to successfully intubate the patient for anesthesia
prior to tubal ligation. It was felt that the procedure
should have been postponed if optimal anesthesia
could not be safely obtained.
A diabetic patient 20 days after cesarean section was
readmitted because of mechanical small bowel ob-
struction secondary to a pelvic abscess. She previously
had a paralytic ileus following delivery. Failure to see
the patient sooner after discharge from the hospital
was felt to be a factor in her demise.
RECOMMENDATIONS
Since the purpose of the review of maternal deaths
is educational, the following observations are pres-
ented:
A. 81— NUMBER 11— NOVEMBER 1984 937
TABLE 6
Prevent ability of Maternal Deaths
v Indirect Causes
8
Nonpreventable
6
Preventable
2
5. Direct Causes
12
Nonpreventable
4
Preventable
8
1. Physician factor
8
2. Patient factor
1*
One death had physician and patient factor
[ otured. A pathologic retraction ring was found at
Idopsy. While cesarean section on a 270-pound
i man with a dead baby would be difficult and frus-
t ting, the attempted version was ill advised.
)ne patient died of a septic pulmonary embolus two
eks after postpartum tubal ligation. Another patient
d five days after sterilization due to ileus secondary
torsion of the greater omentum. These cases remind
that sterilization of the female is not an innocuous
rcedure and such patients must be monitored as
'efully after surgery as any patient undergoing ab-
I minal surgery.
V ease of amniotic fluid embolism was felt to be
' *ven table because a tear in the anterior lower
1. The presence of cardiac problems should be de-
termined by careful history and physical evaluation.
The first physician who sees an adult female may be
the physician who will deliver her infant. The initial
examination may disclose a previously undiagnosed
cardiac defect that must be followed closely. This rec-
ommendation applies to all pre-existing conditions
which diligently should be searched for as they in-
fluence the number of maternal deaths.
2. Postpartum tubal ligation is an operation that
has all the risks of any abdominal procedure. As it is
an elective operation, surgery can and should be post-
poned if the patient has any problem or condition that
merits evaluation before the procedure is performed.
The patient should receive the same careful pc
operative care as she would have received for j
laparotomy. It should be noted that six mater
deaths were associated with a sterilization procedi
3. Careful outpatient followup of all surgical
tients, especially diabetics, is essential.
REFERENCES
1. New Jersey State Department of Health: Maternal
Child Health Program, Program Report. Trenton, NJ, IS
2. Hansen GF, Gregory M: Maternal deaths in New J
sey— 1981. J Med Soc NJ 80:261-263, 1983.
3. Braunn AW, Cefalo RC (eds): Guidelines Jor Perini
Care. 202-203, 1983.
i
938
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER Tj
BALANCED
CALCIUM
Low incidence of side effects
CARDIZEM® (diltiazem HC1)
produces an incidence of adverse
reactions not greater than that
reported with placebo therapy,
thus contributing to the patient’s
sense of well-being.
'Cardizem is indicated in the treatment of angina pectoris due to
coronary arteiy spasm and in the management of chronic stable
angina (classic effort-associated angina) in patients who cannot
tolerate therapy with beta-blockers and/ob nitrates or who remain
symptomatic despite adequate doses of these agents.
• References:
1. Strauss WE, McIntyre KM, Parisi AF, et al: Safety and efficacy
of diltiazem hydrochloride for the treatment of stable angina
pectoris: Report of a cooperative clinical trial. Am J Cardiol
49:560-566, 1982. "
2. Pool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise-
inducible chronic stable angina with diltiazem: Effect on treadmill
exercise. Chest 78 (July suppl):234-238, 1980.
Reduces angina attack frequency*
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test,2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (PC.005).
CARDIZEM
(diltiazem. HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
I
Please see full prescribing information on following page.
2/84
PROFESSIONAL USE INFORMATION
cardizem
(diltiazem HCI)
30 and 60 mg tablets
DESCRIPTION
CARDIZEM" (diltiazem hydrochloride) is a calcium ion influx
Inhibitor (slow channel blocker or calcium antagonist). Chemically,
diltiazem hydrochloride is 1,5-Benzothiazepin-4(5H)one,3-(acetyloxy)
-5-[2-(dimethylamino)ethyl]-2,3-dihydro-2-(4-methoxyphenyl)-,
monohydrochloride, (+) -cis-.The chemical structure is:
Diltiazem hydrochloride is a white to ott-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform.
It has a molecular weight of 450.98. Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administration
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle.
Mechanisms of Action. Although precise mechanisms of its
antianglnal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovine-induced cor-
onary artery spasm are inhibited by CARDIZEM.
2. Exertional Angina: CARDIZEM has been shown to produce
increases In exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads.
In animal models, diltiazem interferes with the slow inward
(depolarizing) current in excitable tissue. It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect. The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases In peripheral resistance.
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists, diltiazem decreases sinoatrial and atrioventricu-
lar conduction in isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
Interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm. It causes a decrease in peripheral vascular
resistance and a modest fall in blood pressure and, in exercise
tolerance studies In patients with ischemic heart disease, reduces
the heart rate-blood pressure product tor any given work load.
Studies to date, primarily in patients with good ventricular function,
have not revealed evidence of a negative inotropic effect: cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
ot diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater than first-degree
AV block. Diltiazem-associated prolongation of the AH interval is not
more pronounced in patients with first-degree heart block. In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and Metabolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine. In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins. Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxin, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration. The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours. Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem Therapeutic blood levels of
CARDIZEM appear to be in the range ot 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given: a 120-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem.
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Artery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment ot spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM has been effective in controlled trials in
reducing angina freguency and Increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with Impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence ot a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a tunctioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1 . Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome. This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0.48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on cardiac conduction. A patient with Prinzmetal's
angina developed periods of asystole (2 to 5 seconds) after a
single dose ot 60 mg ot diltiazem
2 Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited. Caution should
be exercised when using the drug in such patients.
3. Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4 Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals. The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued. In dogs,
doses of 20 mg/kg were also associated with hepatic changes:
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated Available data are not sufficient, however, to predict
the effects ot concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities. In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21-month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests. No intrinsic effect on fertility was observed
in rats.
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities. In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women; therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman if the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded.
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition. In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are; edema (2.4%),
headache (2.1%), nausea (1.9%), dizziness (1.5%), ras .<
asthenia (1.2%), AV block (1.1%). In addition, the followiirt
were reported infrequently (less than 1%) with the order of !j
tion corresponding to the relative frequency of occurrence
Cardiovascular:
Nervous System:
Gastrointestinal:
Dermatologic:
Other:
Flushing, arrhythmia, hypotension, M
dia, palpitations, congestive heauic
syncope.
Paresthesia, nervousness, soma
tremor, insomnia, hallucinations, and m
Constipation, dyspepsia, diarrhea, m
mild elevations of alkaline phosphata 3
SGPT, and LDH
Pruritus, petechiae, urticaria, photo; i
Polyuria, nocturia.
The following additional experiences have been noted:
A patient with Prinzmetal's angina experiencing ep r
vasospastic angina developed periods of transient asyr a
asystole approximately five hours after receiving a sine »
dose of CARDIZEM
The following postmarketing events have been repoi
quently in patients receiving CARDIZEM erythema multit si
kopenia, and extreme elevations ot alkaline phosphata: S
SGPT, LDH, and CPK, However, a definitive cause and effec ii
these events and CARDIZEM therapy is yet to be establi: If
QVERDOSAGE OR EXAGGERATED RESPON!
Overdosage experience with oral diltiazem has bee
Single oral doses ot 300 mg of CARDIZEM have been wel
by healthy volunteers In the event of overdosage or ex
response, appropriate supportive measures should be era
addition to gastric lavage. The following measures may be w
Bradycardia
High-Degree AV
Block
Cardiac Failure
Hypotension
Administer atropine (0.60 to 1.0 mi
is no response to vagal blockade, ;
isoproterenol cautiously.
Treat as for bradycardia above. F
degree AV block should be treated
diac pacing.
Administer inotropic agents (isop
dopamine, or dobutamine) and diure
Vasopressors (eg, dopamine or le
bitartrate).
Actual treatment and dosage should depend on the sevi
clinical situation and the judgment and experience of tt
physician
The oral/LD50's in mice and rats range from 415 to 7
and from 560 to 810 mg/kg, respectively. The intravenou
these species were 60 and 38 mg/kg, respectively. The o
dogs is considered to be in excess of 50 mg/kg, while lei
seen in monkeys at 360 mg/kg. The toxic dose in man is r
but blood levels in excess of 800 ng/ml have not been t
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atherosclerc
nary Artery Disease or Angina Pectoris at Rest Dui
nary Artery Spasm. Dosage must be adjusted to eacl
needs Starting with 30 mg four times daily, before me
bedtime, dosage should be increased gradually (given
doses three or four times daily) at one- to two-day intej
optimum response is obtained. Although individual pat:
respond to any dosage level, the average optimum dos
appears to be 180 to 240 mg/day. There are no available da
ing dosage requirements in patients with impaired renal ;
function. It the drug must be used in such patients, titration
carried out with particular caution.
Concomitant Use With Other Antianglnal Agent:;
1. Sublingual NTG may be taken as required to a |
anginal attacks during CARDIZEM therapy.
2 Prophylactic Nitrate Therapy -CARDIZEM mays
coadministered with short- and long-acting nitrates I
have been no controlled studies to evaluate the ill
effectiveness of this combination.
3. Beta-blockers. (See WARNINGS and PRECAUTION:
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles of
0088-1771-47) and in Unit Dose Identification Paks of
0088-1771-49). Each green tablet is engraved with MARI;
side and 1771 engraved on the other. CARDIZEM 60-r
tablets are supplied in bottles of 100 (NDC 0088-1 772-47);
Dose Identification Paks of 100 (NDC 0088-1772-49). Ei
tablet is engraved with MARION on one side and 1772 oi
Issul
;
!
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES. INC
KANSAS CITY, MISSOURI 64137
Ceftriaxone, a Third
GENERATION CEPHALOSPORIN
Edward S. Johnson, m.d., Marc Fedder, m.d., Leon G. Smith, m.d., Newark*
:
i
i
I
l
i
Ceftriaxone is a new third generation cephalosporin with an
inusually prolonged half-life and broad antibacterial
ipectrum. These properties decrease length of hospital stay.
)ur studies show ceftriaxone as a safe and effective
mtibioticfor serious bacterial infections.
i
eftriaxone, a new third gener-
■ ation cephalosporin, has good
activity against gram-positive
1 gram-negative bacteria and has increased stability
dnst various types of beta-lactamases. 1 Ceftriaxone
> a prolonged serum half-life of 6.5 h to 8.6 h and
drug can be given at longer time intervals than
st other conventional antibiotics.2 Ceftriaxone pen-
ates into the cerebrospinal and intestinal fluids
dily and the elimination from these compartments
Islower than other related B-lactam antibiotics.3
TERIALS AND METHODS
|eftriaxone was used to treat 46 patients and of
jse, 38 patients met the clinical criteria for evalu-
>n in this study. The 8 patients who were excluded
In the study included 5 patients with no bacterial
hogen isolated, and 3 patients who signed out of
hospital against medical advice.
jJl of the patients in this study were treated as inpa-
its at Saint Michael’s Medical Center, Newark. Pa-
lts were selected on the basis of documented infec-
I'ls or suspected bacterial infections after being
luated by the infectious diseases staff. All of the
dents were 18 years or older and written consent
Is obtained from all of the patients. Cultures were
Gained prior to starting patients on ceftriaxone ther-
! . A culture was repeated usually 48 hours after
'ting therapy and where clinically indicated or
I
C 81 -NUMBER 11 -NOVEMBER 1984
feasible at the end of therapy. A bacterial organism was
isolated on all patients in the group that was evaluated.
Ceftriaxone (Ro 13-9904) is a 2-aminothiazolyl
methoxyimino cephalosporin derivative.4 The drug
was obtained from Hoffmann-La Roche, Inc., and was
in the form of a crystalline powder. The drug was ad-
ministered every 12 or 24 hours either intramuscular-
ly or intravenously. The drug was diluted with water
and mixed with 50 cc of D5W or 50 cc of normal saline
for intravenous use. For intramuscular use, the drug
was mixed with 1 percent lidocaine hydrochloride
solution. Lidocaine was used in place of sterile water
to minimize discomfort of the intramuscular injection.
Many of the patients with osteomyelitis were treated
as outpatients after initial evaluation and treatment
as inpatients. A daily intramuscular injection was
given for these patients. The bacterial isolate suscep-
tibility of ceftriaxone was determined by standardized
Kirby-Bauer technique. The minimal inhibitory con-
centrations for all isolates were determined by the
microliter technique (Dynatech). Tiypticase Soy broth
was used with an inoculum of culture containing 105
colony-forming units per ml of an overnight broth.
Osteomyelitis was diagnosed by aspiration cultures
of the bone or by bone biopsy cultures. Radiology stud-
*Dr. Smith is Director, Department of Medicine. Saint
Michael’s Medical Center. Newark. Correspondence may be
addressed to Dr. Smith, Saint Michael’s Medical Center, 268
Martin Luther King, Jr. Blvd., Newark, NJ 07102.
941
ies and bone and gallium scans were used to support
the diagnosis. A clinical cure was defined as resolution
of local and systemic symptoms of the patients and a
bacteriologic cure was defined as a sterile culture. The
patients with osteomyelitis who had no further
drainage and had radiologic changes such as resolving
osteomyelitis were evaluated as a clinical improve-
ment. Those patients who had complete resolution of
their osteomyelitis were evaluated as clinical cure.
Pneumonia was diagnosed by a positive culture,
positive gram stains of the sputum, and radiographic
evidence of a pulmonary infiltrate. Cure of pneumonia
was established when sputum cultures were negative
and the infiltrate in the chest x-ray had resolved.
Skin and soft tissue infection was based on a
positive culture and the clinical involvement of the
skin and soft tissue. The skin and soft tissue infec-
tions were defined as cured when the tissues healed
to their normal visual and tonic configuration.
A diagnosis of pyelonephritis was made by fever,
costovertebral angle tenderness, and positive culture.
A cure was defined as a sterile culture at five to nine
days post-therapy, and when clinical symptoms had
abated.
In the eases of meningitis, typhoid fever, and
gangrene, the appropriate sites were cultured
(cerebrospinal fluid, blood, or urine) and a diagnosis
was based on proper isolation of the infecting or-
ganism. These miscellaneous entities were defined as
cured when appropriate cultures were sterile. In our
patient with meningitis, a cell count with differential
glucose and protein was done on the cerebrospinal
fluid. This was repeated for a total of four times
throughout the patient’s two-month course.
All of the patients in this study were monitored for
toxicity of ceftriaxone; complete blood counts, includ-
ing differential counts and platelet counts, were done
on each patient. Other laboratory tests included BUN,
creatinine, SGOT, SGPT, alkaline phosphatase,
bilirubin, and urine analysis (biochemical and micro-
scopic). This was repeated every four days while the
patient was on ceftriaxone or where clinically in-
dicated. The patients were followed daily by a member
of our attending infectious diseases staff.
RESULTS
In the 20 patients who were treated for osteomyelitis
with ceftriaxone, 16 patients had a bacteriologic cure
of their disease. Three patients had resistant or-
ganisms but did show clinical improvement after
being treated with ceftriaxone. Patient 12, having
sensitive organisms to ceftriaxone, did not respond
clinically to the medication. The patient was treated
with vancomycin and rifampin and responded clinical-
ly and a cure was obtained. There were 9 chronic cases
and 7 acute cases that were cured, and several of these
patients had numerous bacterial isolates. The or-
ganisms isolated in the 17 sensitive cases included 1 1
isolates of Staphylococcus aureus, 4 isolates of S.
epidermidis, 4 isolates of Escherichia coli, 2 isolates
of Proteus mirabilis, 2 isolates of Acinetobacter
anitratus, 2 isolates of Enterobacter cloacae, and 1
isolate of Salmonella enteritidis and Pseudomonas
aeruginosa, Bacteroides ovatus was resistant to cef-
triaxone and clindamycin in patient 11. However, it
was sensitive to the tetracyclines. The 3 patients
whom resistant organisms were found had the folio
ing bacterial isolates; 2 isolates of S. epidermidis;
isolate each of enterococci and E. cloacae. Patient
had a hip prosthesis in place which may have ;
tributed to failure of ceftriaxone. In our series, 2 p
tients required surgical intervention because
abscess cavities within the bone. One of these patier,
(11) later was found to have Ehlers-Danlos disea;
This may have attributed to her poor wound healii
Eleven of our patients were treated as outpatier
after initial hospitalization and evaluation. All exce
1 could tolerate the intramuscular injections as outp
tients and that patient was readmitted for intraveno
therapy. Ceftriaxone was well tolerated by our patien
only 1 patient had a transient rise of liver trar
aminases. In our 9 chronic cases and 7 acute eas.
that were cured, improvement was noted radiologica,
The chronic cases either had resolving osteomyelii
or resolution of osteomyelitis on x-ray and bone a I
gallium scans. All of our 7 acute cases had comple
resolution of osteomyelitis on x-ray and bone gallic i
scans. The dosing interval in our osteomyelitis cal
was 12 to 24 hours and total dosages ranged from
to 84 gm over a time interval of 15 to 44 days. Thd
chronic osteomyelitis patients need long-term eva
ation to see if there was a clinical and bacteriolo,:
cure under the period of observation.
Our skin and soft tissue infections included fc
cases of cellulitis; pathogens isolated indue I
Staphylococcus aureus (three), group a be
hemolytic strep (one), and group b strep (one). The
patients responded well to therapy with complete re
lution of their lesions. Other sites of infection indue I
facial abscess, postoperative thoracotomy wound inf •
tion, and ulcer of the right leg. Patient 25, with fac
abscess, had recurrent abscess since childhood a:
recurrence could not be prevented. The patient hi
extensive immunologic and bacteriologic studies. Jo
syndrome was a consideration, but the evaluation wl
negative for any disease entity. S. epidermidis vjl
isolated from the facial abscess. S. aureus a
enterococci were isolated from the postoperat
wound infection and S. aureus was isolated from tj
leg ulcer. All of these patients responded to there!1
with complete resolution of their infections.
We had four cases of pneumonia and our isola
included Streptococcus pneumoniae (two), group
beta-hemolytic streptococci (two), and group b be
hemolytic streptococci (one). All responded to then
and had complete resolution of chest x-ray findirjj
within five to six days and sterile sputum or !
sputum.
All patients with pyelonephritis had Escherichia c i
(four) and Proteus mirabilis (one). All patients
sponded with clearing of urine of bacteria and re
lution of costovertebral angle tenderness and feve
Miscellaneous infections treated with ceftriaxone
eluded: meningitis, typhoid fever, and gangrene of I '
right great toe. Ceftriaxone was used to tn;
Enterobacter cloacae meningitis. The patient suffei'l
severe trauma in an automobile accident and had fr
tured vertebrae with leaking cerebrospinal fluid,
had prior treatment with ampicillin and gentamicin !
another hospital. The levels of gentamicin were the ■
942
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1,
TABLE
Site of Clinical Infection, Bacteriology, Response, and Duration of Therapy
in 38 Patients Who Received Ceftriaxone for 5 or More Days
Site of Infection
Bacteria Isolated
Response Clinically
Days of Therapy
Osteomyelitis
Staphylococcus aureus
Cure
42
Osteomyelitis
Escherichia coli
Cure
21
Osteomyelitis
Enterococci, Enterobacter cloacae
Failure
6
Osteomyelitis
Salmonella enteritidis
Cure
34
Osteomyelitis
S. aureus
Cure
46
Osteomyelitis
S. epidermidis
Cure
42
Osteomyelitis
Osteomyelitis
S. aureus
Cure
40
S. aureus
Cure
42
Osteomyelitis
S. epidermidis
Improved clinically
but baeteriologic failure
42
Osteomyelitis
Acinetobacter anitratus,
E. cloacae.
E. coli. S. aureus
Cure
42
Osteomyelitis
E. cloacae.
S. aureus. E. coli.
Bacteroides ovatus
Cure
42
Osteomyelitis
S. aureus. S. epidermidis
Clinical failure
15
Osteomyelitis
S. epidermidis
Failure
42
Osteomyelitis
|
P. mirabilis.
S. epidermidis
Cure
15
{ Osteomyelitis
Acinetobacter anitratus
Cure
41
Osteomyelitis
P. mirabilis
Cure
43
Osteomyelitis
S. aureus
Cure
42
Osteomyelitis
S. aureus
Cure
42
Osteomyelitis
S. aureus
Cure
42
Osteomyelitis
Pseudomonas aeruginosa,
E. coli
Cure
35
Cellulitis
S. aureus
Cure
10 '/2
Cellulitis
S. aureus
Cure
7
Cellulitis
S. aureus
Cure
8
Cellulitis
S. aureus.
Group a Streptococcus
Cure
1 7 Vi
Facial abscess
S. epidermidis
Clinical improvement
1 1
Wound infection
'
S. aureus.
Enterococci
Cure
21
Leg ulcer
S. aureus
Cure
8
Pneumonia
H. influenza
Cure
6
Pneumonia
Streptococcus pneumoniae
Cure
5
Pneumonia
Group a beta streptococci
Cure
8
Pneumonia
Streptococcus pneumoniae
Cure
6
Pyelonephritis
E. coli
Cure
6
Pyelonephritis
E. coli P. mirabilis
Cure
1 1
Meningitis
E. cloacae
Cure
27
Typhoid Fever
Salmonella typhi
Cure
1 1
Gangrene great toe
Serratia marcescens
Cure
14
(l. 81— NUMBER 11 -NOVEMBER 1984
943
peutic at peak and trough and the maximum dose of
ampieillin was given (12 gm), but the E. cloacae was
not eradicated from the cerebrospinal fluid. In our hos-
pital, the E. cloacae (MIC 2.0 mg/ml) was resistant to
ampieillin but sensitive to gentamicin. The patient was
treated with gentamicin 60 mg intravenously every
Q8H for 34 days and intrathecal gentamicin 7 mg
three times daily for 9 days concurrently with ceftria-
xone (2 g intravenously Q8H). After 6 days of combined
drug therapy repeat cultures from the cerebrospinal
fluid were sterile. The patient went on to have an un-
eventful recovery.
Our one case of typhoid fever responded well to cef-
triaxone. Salmonella typhi was isolated from three
blood cultures but was not isolated from the stool.
Repeat blood cultures, done five days after treatment
with ceftriaxone were sterile. The patient was treated
with intramuseular/intravenous ceftriaxone for seven
days and for four days as an outpatient. The patient
then was followed up by her local medical doctor; at
the end of six months she has had no further relapse
of her disease.
The patient with gangrene of the right great toe had
Serratia marcescens and Escherichia coli isolated
from the wound. Treatment with ceftriaxone resulted
in sterile cultures but eventually the toe was am-
putated. The patient recovered.
In our study, ceftriaxone has been found to be highly
active against gram-positive and gram-negative or-
ganisms. Ceftriaxone also inhibited members of the
enterobacteriacae at lower concentrations than older
cephalosporins and its activity against Escherichia
coli and Klebsiella pneumoniae was similar to that
of cefotaxime and moxalactam.5 The long elimination
half-life of ceftriaxone of approximately 8.2 hours
should make this drug veiy useful for the treatment
of outpatients, especially those with osteomyelitis.4
The advantage of using ceftriaxone in the treatment
of osteomyelitis is that its prolonged serum half-life
allowed us to treat 1 1 of our 20 patients as outpatients,
with a once-a-day treatment regimen. All outpatients
tolerated the intramuscular injections except 1 patient
who was readmitted for intravenous treatment. In the
3 patients with osteomyelitis who failed clinically, 1
of these patients had a hip prosthesis in place; 2 had
Staphylococcus epidermidis and 1 of these patients
had enterococci and Enterobacter cloacae. Ceftria-
xone, like other new B-lactam antibiotics, has redud
activity against staphylococci species compared to tl
first and second generation cephalosporins such
cephalothin and cefamandole.6 7 However, t
achievable serum concentrations of ceftriaxone far e
ceed the MIC for most staphylococcal specie
Cephalosporins in general are not very effecti
against the enterococci.8 Only 1 patient had a tran
ent increase in SGOT and SGPT which resolved. It a]
will be beneficial in those patients with serio
bacterial infections who can be treated on an out]:
tient basis/osteomyelitis and typhoid fever. This
fieaey along with favorable pharmacokinetics sho
that ceftriaxone should be useful in the treatment :
serious bacterial infections. If this drug is priced prc
erly, it could revolutionalize the method of treati ;
osteomyelitis, soft tissue infections, pneumonias, a I
conceivably even meningitis as an outpatie
procedure. This is a major factor in hospital cost cc
tainment today as hospital stay was reduced by i
percent in major illnesses.
REFERENCES
1. Patel IH, Weinfeld RE, Konikoff J, Parsonnet M: Pham
eokinetics and tolerance of ceftriaxone in humans ai
single-dose intramuscular administration in water and li<
caine diluents. Antimicrob Agents Chemother 21:402-4
1982.
2. Epstein J, Hasselquist S, Simon G: Efficacy of cefti
xone in serious bacterial infections. Antimicrob Age ;
Chemother 21:402-406, 1982.
3. Johnson RC, Bey RE, Wolgamot SJ: Comparison of i:
activities of ceftriaxone and penicillin G against expertm
tally induced syphilis in rabbits. 1982. Antimicrob Age >
Chemother 21:984-988, 1982.
4. Beskid G, Cleeland W, Deloreno A Trown PW: In v>
activity of ceftriaxone (Ro 13-9904) a broad spectrum sei
synthetic cephalosporin. Antimicrob Agents Chemot Jr
20:159-167, 1981.
5. Neu H, Merpol N, Kwung F: Antibacterial activity of (j-
triaxone (Ro 13-9904) a B-lactamase stable cephalospoi .
Antimicrob Agents Chemother 19:44-423, 1981.
6. Eickhoff TC, Ehret J: Comparative in vitro studies of >
13-9904 a new cephalosporin derivative. Antimicrob Ages
Chemother 18:240-242, 1981.
7. Angehm P, Probst P, Reiner R Then R Ro 13-990!
long-acting broad spectrum cephalosporin: In vitro and i
vivo studies. Antimicrob Agents Chemother 18:913-9,
1980.
8. Thompson RL, Wright AJ: Cephalosporin antibiot
Mayo Clinic Proc 58(2): 79-87. 1980.
944
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS '
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L. 81— NUMBER 11— NOVEMBER 1984
945
“When the Ayerst rep told me
it costs about 454 a day,
I said you can stop right there.”
Most doctors are pleasantly surprised to learn that the average cost of
daily therapy with the world’s most widely used beta blocker is so little,
not much more than the cost of a daily newspaper.
When it’s INDERAL tablets (propranolol hydrochloride) you want for
your hypertension patients, remember to specify Dispense As Written
(DAW) or Do Not Substitute on your prescriptions. That way, you can
always be assured they’ll get INDERAL®.
Please see next page for brief summary of prescribing information.
“When the Ayerst rep told me
it costs about 45<t a day,
I said you can stop right there.”
Inderal
(PROPRANOLOL HCI)
10 mg 20 mg 40 mg 60 mg 80 mg 90 mg*
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL® (propranolol hydrochloride) Tablets
CLINICAL PHARMACOLOGY
The Beta-Blocker Heart Attack Trial (BHAT) was a National Heart, Lung and Blood Institute-
sponsored multicenter, randomized, double-blind placebo-controlled trial conducted in 31
U S, centers (plus one in Canada) in 3,837 persons without history of severe congestive heart
failure or presence of recent heart failure; certain conduction defects; angina since infarction,
who had survived the acute phase of myocardial infarction Propranolol was administered at
either 60 or 80 mg t i d based on blood levels achieved during an initial trial of 40 mg t.i d
Therapy with INDERAL, begun 5-21 days following infarction, was shown to reduce overall
mortality up to 39 months, the longest period of follow-up This was primarily attributable to a
reduction in cardiovascular mortality The protective effect of INDERAL was consistent
regardless of age, sex or site of infarction. Compared to placebo, total mortality was reduced
39% at 12 months and 26% over an average follow-up period of 25 months. The Norwegian
Multicenter Trial in which propranolol was administered at 40 mg q.i.d. gave overall results
which support the findings in the BHAT
Although the clinical trials used either t.i.d. or q.i.d dosing, clinical, pharmacologic and
pharmacokinetic data provide a reasonable basis for concluding that b i d. dosing with pro-
pranolol should be adequate in the treatment of post-infarction patients.
CLINICAL In the BHAT, patients on INDERAL were prescribed either 180 mg/day (82% of
patients) or 240 mg/day (18% of patients). Patients were instructed to take the medication 3
times a day at mealtimes. This dosing schedule would result in an overnight dosing interval of
12 to 14 hours which is similar to the dosing interval for a b i d regimen In addition, blood
samples were drawn at various times and analyzed for propranolol When the patients were
grouped into tertiles based on the blood levels observed and the mortality in the upper and
lower tertiles were compared, there was no evidence that blood levels affected mortality
PHARMACOLOGIC Studies in normal volunteers have shown that a 90 mg b i d regimen
maintains beta blockade at, or above, the minimum for 60 mg t.i.d dosing for 24 hours even
though differences occurred at two time intervals. At 10-12 hours after the first dose of the day,
t.i.d. dosing gave more beta blockade than b.i d. dosing; at 20-24 hours the trend of the rela-
tionship was reversed These relationships were similar In direction to those observed for
plasma propranolol levels (see Pharmacokinetic).
PHARMACOKINETIC; A bioavailabihty study in normal volunteers showed that the blood
levels produced by 180 mg/day given b i d are below those provided by the same daily dos-
age given t.i.d at 10-12 hours after the first dose of the day but above those of a t.i d. regimen
at 20-24 hours. However, the blood levels produced by b.i d dosing were always equivalent
to or above the minimum for t.i.d. dosing throughout the 24 hours. In addition, the mean AUC
on the fourth day for the b.i d. regimen was about 17% greater than for the t.i.d. regimen (1,194
vs. 1,024 ng/ml- hr)
CONTRAINDICATIONS
INDERAL is contraindicated in 1) cardiogenic shock, 2) sinus bradycardia and greater than
first degree block, 3) bronchial asthma, 4) congestive heart failure (see WARNINGS) unless
the failure is secondary to a tachyarrhythmia treatable with INDERAL.
WARNINGS
CARDIAC FAILURE. Sympathetic stimulation may be a vital component supporting circula-
tory function in patients with congestive heart failure, and its inhibition by beta blockade may
precipitate more severe failure Although beta blockers should be avoided in overt conges-
tive heart failure, if necessary they can be used with close follow-up in patients with a history
of failure who are well compensated and are receiving digitalis and diuretics. Beta-
adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible)
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks and the patient should be cau-
tioned against interruption or cessation of therapy without the physician's advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) PATIENTS WITH
BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA BLOCKERS.
INDERAL (propranolol hydrochloride) should be administered with caution since it m
bronchodilation produced by endogenous and exogenous catecholamine stimulatioi
receptors.
MAJOR SURGERY; The necessity or desirability of withdrawal of beta-blocking the
prior to major surgery is controversial. It should be noted, however, that the impaired .
the heart to respond to reflex adrenergic stimuli may augment the risks of general an<
and surgical procedures.
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agom
its effects can be reversed by administration of such agents, e.g dobutamine or isop
terenol. However, such patients may be subject to protracted severe hypotension Dh
starting and.maintaining the heartbeat has also been reported with beta blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the app
ance of certain premonitory signs and symptoms (pulse rate and pressure changes)
hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be more I
to adjust the dosage of insulin.
THYROTOXICOSIS; Beta blockade may mask certain clinical signs of hyperthyroidism |
fore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptc |
hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have i
reported in which, after propranolol, the tachycardia was replaced by a severe bradj j
requiring a demand pacemaker. In one case this resulted after an initial dose of 5 mg
propranolol
PRECAUTIONS
General. Propranolol should be used with caution in patients with impaired hepatic o
function. INDERAL is not indicated for the treatment of hypertensive emergencies.
Beta-adrenoreceptor blockade can cause reduction of intraocular pressure Patiei
should be told that INDERAL may interfere with the glaucoma screening test Withdr;
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart c
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such a
pine should be closely observed if INDERAL is administered The added catecholarr
blocking action may produce an excessive reduction of resting sympathetic nervous
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, on
static hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animal
been conducted to evaluate toxic effects and carcinogenic potential In 18-month stu
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence ol
cant drug-induced toxicity. There were no drug-related tumorigemc effects at any of
age levels Reproductive studies in animals did not show any impairment of fertility tt
attributable to the drug.
Pregnancy Pregnancy Category C INDERAL has been shown to be embryotoxic f
studies at doses about 10 times greater than the maximum recommended human do|r
There are no adequate and well-controlled studies in pregnant women INDERAL : i
be used during pregnancy only if the potential benefit justifies the potential risk to the I
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercise f
INDERAL is administered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS
Most adverse effects have been mild and transient and have rarely required the with;l
therapy
Cardiovascular bradycardia; congestive heart failure; intensification of AV block, it
sion; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency usually jl
Raynaud type
Central Nervous System: Lightheadedness; mental depression manifested by msi I
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia (
disturbances; hallucinations; an acute reversible syndrome characterized by disorie I
for time and place, short-term memory loss, emotional lability, slightly clouded senso I
and decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diaril
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined witjl
and sore throat, laryngospasm and respiratory distress.
Respiratory , bronchospasm
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopeniql
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has ben
reported.
Miscellaneous alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male in,-
tence, and Peyronie's disease have been reported rarely Oculomucocutaneous rea *
involving the skin, serous membranes and conjunctivae reported for a beta blocker jit
lol) have not been associated with propranolol
•The appearance of INDERAL tablets is a registered trademark of Ayerst Laboratoj
9371/1
Ayerst
AYERST LABORATORIES
New York, N Y. 10017
I
948
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERJi'
Aortic and Mitral Valve
Replacement: Part 1*
Philip J. Olivieri, m.d., and John B. Kostis, m.d., new Brunswick**
The development of valvular pro theses and reconstructive
procedures has revolutionized the management of valvular heart
disease . Part 1 will discuss the clinical presentation and natural
history of aortic stenosis, mitral stenosis, aortic regurgitation,
and mitral regurgitation without surgery .
It has been nearly a quarter of a
century since the first aortic
and mitral prostheses were in-
;rted by Harken, Starr, and Edwards.12 Since then,
alve replacement has revolutionized the management
f valvular heart disease. The clinical course of the
reprosthetic era, often characterized by a latent
eriod of variable duration followed by inexorable de-
coration and death, has been modified so that a
itum to normal or near-normal cardiac function is
ossible.
As Kirklin and Pacifico have stated, “The value to the
atient of valve repair or replacement is determined by
le resulting improvement in the length and quality
r life over that imposed by the natural history of the
isease.”3 Accurate knowledge of the natural history of
le valvular lesions is thus of great importance.
This article reviews the natural history of aortic and
ritral stenosis and regurgitation, the results of sur-
ety, and the crucial issue of timing of surgical inter-
ention. Finally, special considerations including re-
air of native valves and replacement of prosthetic
lives will be discussed.
ORTIC STENOSIS
Aortic stenosis is characterized by a reduction in the
iDrmal (2 to 4 cm2) valve area and a systolic pressure
'adient between the left ventricle and the aorta at the
rlvular level. It usually develops across nonobstructed
bicuspid valves damaged by turbulent flow with sec-
ondary calcification.7 Anatomically normal valves also
can calcify (“wear and tear” stenosis in the elderly).
Congenital unicuspid, bicuspid, or tricuspid stenosis
is seen and rheumatic stenoses occur. Regardless of
the etiology, aortic stenosis is a self-perpetuating pro-
cess whose rate of progression is not predictable.
Bogart et al. studied 1 1 adult patients (mean age 48
years) with two cardiac catheterizations (mean interval
59 months): they had not had aortic valve surgery.8
They found progression in 10 patients with a decrease
of mean valve area from 1.2 ± 0.2 cm2 to 0.7 ±0.1 cm2;
and an increase in mean left ventricular-aortic gra-
dient from 31 ± 4 mm/Hg to 75 ± 13 mm/Hg. The
shortest time interval was from 27 to 29 months.
Cheitlin et al. performed 31 sets of catheterizations (62
catheterizations in total) on 29 unoperated adults with
aortic stenosis (mean interval, 43.5 months.)9 They
found an increase in the peak systolic gradient across
the aortic valve of at least 50 percent in 16 of the 31
studies. In the progressive group, the average rate of
increase was 1.3 mm/Hg/month with a maximum rate
of 3.8 mm/Hg/month observed. Although a long latent
period typifies aortic stenosis, it is clear that the pro-
*Part 2 will appear in the next issue of The Journal. MSNJ.
**From the Division of Cardiovascular Diseases, UMDNJ-
Rutgers Medical School. Correspondence may be addressed
to Dr. Kostis, UMDNJ-Rutgers Medical School. CN 19, New
Brunswick. NJ 08903.
pL. 81— NUMBER 11— NOVEMBER 1984
949
COMPOSITE SURVIVAL DATA FOR VALVULAR LESIONS
WITH MEDICAL MANAGEMENT
300
Survival Data
I ! I
Lv~
X?
Ao
Figure 1 — Aortic stenosis. Left panel: Postextrasystolic poten-
tiation. Note the increased systolic pressure in the post-
extrasystolic beat (large arrow). Flight panel: Transvalvular
gradient on left ventricular (LV) to aortic (Ao) pullback.
AS: Rapaport & Frank
MS: Rapaporl & Rowe
AR Rapaporl & Spagnuolo j
MR: Rapaport & Hammerme:
Figure 2 — Composite survival data for valvular lesions vl
medical management.
gression of this lesion can be quite rapid. The con-
ditions predisposing toward rapid progression remain
largely unknown. Wagner and Selzer recently reviewed
50 adult patients (mean age 54 ± 4 years) with aortic
stenosis (peak left ventricular-aortic gradient 38 ± 27
mm/Hg; valve area 1.3 ± 0.7 cm2.)10 There were 7 pa-
tients with congenital and 22 patients with rheumatic
lesions. An older group of patients (mean age 62 versus
51 ± 9 years) had degenerative-calcific aortic stenosis.
A second cardiac catheterization 3.5 ± 3 years later
revealed a gradient of 57 ± 30 mm/Hg and a valve area
of 0.8 ± 0.4 cm2 for all patients. The group divided into
21 rapid progressors (0.3 ± 0.21 em2/year) and 29 slow
progressors (0.02 ± 0.08 em2/year). Seventy-six per-
cent of the rapid progressors had degenerative-calcific
aortic stenosis as opposed to only 21 percent of the
slow progressors.
Adults, unlike children, rarely are asymptomatic
when significant aortic stenosis is present. The pres-
ence of symptoms in medically managed aortic
stenosis suggests an ominous prognosis: angina, syn-
cope, and congestive heart failure portend death on the
average of five, three, and two years, respectively." In
addition, even asymptomatic patients remain at in-
creased risk for sudden death. The physical findings
include a narrow pulse pressure, delayed carotid up-
stroke and peripheral pulses, sustained left ventricular
heave, S4 gallop, and a harsh aortic systolic ejection
murmur radiating to the carotid arteries. These find-
ings together with noninvasive data select patients for
invasive study. The noninvasive data include valve
calcification on chest x-ray or fluoroscopy, left ven-
tricular hypertrophy with strain pattern on elec-
trocardiogram, and increased left ventricular posterior
wall or septal thickness, or nonvisualized aortic leaflets
on echocardiogram. Cardiac catheterization, with the
demonstration of a left ventricular-aortic gradient
greater than 50 mm/Hg (Figure 1 ) or a calculated valve
area less than 0.4 cm2/m2 body surface area, is
diagnostic of hemodynamically important aortic
stenosis. The aortic valve area should be determined
when possible (i.e. in the absence of concomitant aortic
regurgitation) since patients with critical stenosis may
have small left ventricular-aortic gradients due to a
decrease in cardiac output.
The poor prognosis of aortic stenosis with medical
management has been documented in several studies
(Table). These studies should be compared with cau-
tion: statistical methods differ and current medi,
practices obviously are not reflected in the early
ports. Nevertheless, the data of Bergeron et al„ Wo .
Takeda et al., and Rotman et al. reflect a wide ran
of clinical experience.12 15 Combined data from t
studies of Frank et al. and Rapaport are shown i
Figure 2. 16 7 The five-year and ten-year survivals in th
pooled group are 40 percent and 18 percent, respecti ■
ly. More recently, Schwarz et al. found a 21 percent
year survival among 19 adults with severe aoi:
stenosis (left ventricular-aortic gradient 89.6 ± 1 ]
mm/Hg) who refused surgery.17 This dismal outco :
contrasted sharply with the results of surgical m;-
agement.
MITRAL STENOSIS
Mitral stenosis is characterized by a reduction in t ;
normal (3 to 4 cm2) valve area and a diastolic pressu
gradient between the left atrium and the left ventri?
at the valvular level. It does not cause pressure or v
ume overload of the left ventricle. The etiology of mit 1
stenosis almost exclusively is rheumatic. OtfS
etiologies, including congenital mitral stenosis, <A
rare. However, the lesion probably is perpetuated bjj
nonspecific process akin to that for aortic steno;s
rather than a continuing rheumatic valvulitis.18
The natural history of mitral stenosis depends up i
the interplay of two obstructions to blood flow: a “p
mary” obstruction at the mitral valve and a “secoi-
ary" one at the pulmonary arterioles (Figure 3). In tp
average patient, the lesion is hemodynamically -
significant during the first 10 years after the initl
rheumatic insult when the valve area is above 2.5 cil
Dyspnea develops on exertion after 20 years when li
valve area drops below 2.5 cm2 and appears at rt
when the area drops below 1 .5 cm2. Pulmonary hypo-
tension occurs when the valve area is reduced bel i
1.0 cm2. Unlike aortic stenosis, where symptoms herd
a short, severe course until death, mitral stenosis*
a gradually progressive symptomatic lesion.19 Int-
current complications such as infective endocardi .
atrial fibrillation, or peripheral embolization serve )
alter the basic course.
The physical findings of mitral stenosis are a lo 1
SI (increased Ml), opening snap (S2-OS interval In
than 0.08 seconds with significant lesions), ad
apical diastolic rumble. Left atrial enlargement can -
||
950
THE JOUFtNAL OF THE MEDICAL SOCIETY OF NEW JERS1
-rrsc*' ‘SbE,-
A. Mitral stenosis without pulmonary
vascular disease
B. Mitral stenosis with pulmonary
vascular disease: “secondary stenosis”
gure 3 — Obstructions to blood flow in mitral stenosis. Nor-
al values: Right atrium 5, right ventricle 20/5, pulmonary
tery 20/8 (mean 12), pulmonary capillary and vein 6, left
rium 6, left ventricle 120/6 mm/Hg.
en on the chest x-ray and left atrial abnormality is
esent on the electrocardiogram. Eehoeardiographie
idings essentially are diagnostic: thickened, ab-
irmally moving mitral leaflets on M-mode (Figure 4)
directly visualized small orifice on short-axis view,
o-dimensional mode. Cardiac catheterization still is
quired to measure the transvalvular gradient (Figure
and to calculate the valve area (in the absence of
ncomitant mitral regurgitation), to measure the
llmonary vascular resistance, and to determine the
esenee of concurrent valvular or coronary arteiy
lions.
Survival data in mitral stenosis are presented in the
ible. Data reflect not only the level of available medi-
1 therapy but also the stage at which the patients
itially are assessed. Rowe et al. reported 61 percent
'-year survival among 250 medically treated pa-
nts.20 One-half were asymptomatic when the initial
agnosis was made and one-third were below the age
20 years. A 1 1 5-patient subgroup of the 250 patients
'aracterized by older age and more advanced disease
is followed for 20 years: 45 percent survived for 1 1
ars, 30 percent for 15 years, and 21 percent for 20
ars. Forty-three percent of the subgroup with milder
pease (Rowe’s class 1) had 40 percent 20-year
rvival, whereas 57 percent with greater dysfunction
Ijowe's classes 2 and 3) had only 8 percent 20-year
rvival. These data are consistent with studies by
jssen, Roy and Gopinath, and Munoz et al.2123
II. 81— NUMBER 11— NOVEMBER 1984
Figure 4— Mitral stenosis. This M-mode echocardiogram
demonstrates the classic appearance of mitral stenosis. The
mitral leaflets are thickened and there is anterior diastolic
movement of the posterior leaflet (double arrow). The E-to-F
slope of the anterior leaflet (single arrow) is reduced greatly.
Figure 5 — Mitral stenosis. Transvalvular pressure gradient
obtained by simultaneous recording from catheters in the left
ventricle (LV) and the pulmonary capillary wedge (W). The
variable left ventricular filling in atrial fibrillation accounts
for the beat-to-beat changes.
Rapaport reported 80 percent 5-year and 60 percent
10-year survivals in an unselected group of 133 pa-
tients7. Pooled data from the studies of Rowe et al. and
Rapaport are shown in Figure 2. The 5-year and 10-
year survivals are 75 percent and 60 percent, respec-
tively.
Aortic regurgitation is present when the left ven-
tricle receives backward flow from the aorta during
diastole. Rotman et al. reported 59 patients whose
lesions represented diverse etiologies.15 They included
rheumatic (39 percent), unknown (25 percent),
subacute bacterial endocarditis (10 percent), Marfan’s
syndrome or cystic medial necrosis (8 percent), com-
bined rheumatic/endocarditis (7 percent), luetic (7
percent), ruptured valve (2 percent), and dissecting
aneurysm (2 percent). Asymptomatic periods
measured in decades were frequent with rheumatic,
connective tissue, or luetic lesions.
The most common presentation of aortic regurgi-
tation is congestive heart failure. Angina occurs in
one-third of patients but the typical chronic chest pain
most likely is thoracic wall pain from the hyper-
dynamic precordium.24 Syncope and sudden death are
rare. Physical findings include a hyperdynamic
precordium with an inferolaterally displaced point of
maximum impulse. The S2 is diminished (decreased
A2) and there is an aortic decrescendo diastolic
AORTIC REGURGITATION
951
TABLE
Bergeron et al.
195412
Wood
195813
Takeda et al.14
Rotman et al.
197115
Frank et al.
1973 16
Rapaport
19757
Schwarz et al.
198217
Natural History of Valvular Lesions
Aortic Stenosis
Mitral Stenosis
Retrospective, autopsy series of
100 symptomatic patients: 50
percent survival 2 years after
onset of angina syncope, atrial
fibrillation, or failure. Less than
25 percent 5-year survival.
Series of 64 symptomatic pa-
tients with clinically severe
stenosis (48 pure stenosis, 16
stenosis/regurgitation). One-half
lost to followup 1 to 7 years ob-
servation. Fifty-six percent of the
remaining 32 patients died.
Series of 60 patients with
isolated stenosis. Eighty-two per-
cent dead after 4 to 15 years. Av-
erage age at death was 62.5
years.
Surgical series with 25 medically
treated patients (10 operative
candidates, 15 nonoperative can-
didates). Fifty percent (5/10) 6.1-
year survival versus 79 percent
4.5-year survival.
Series of 15 patients with
stenosis. Survivals of 48 percent
at 5 years and 20 percent at 10
years.
Series of 42 unselected patients
with survivals of 38 percent at 5
years and 20 percent at 1 0 years.
Surgical series with 19 medically
treated patients. Twenty-one per-
cent 3-year survival.
Series of 250 patients (one-hal
asymptomatic, one-third les:
than 20 years old) with 61 per
cent overall 10-year survival: 8^
percent class 1, 42 percent clas:
2, 15 percent class 3 (Rowe’:
classes). An older 115-patien
subgroup had an overall 21 per
cent 20-year survival: 40 percen
class 1, 8 percent classes 2 ani
3.
Series of 271 symptomatic pa
tients (average age 41.5 year
old) first seen 1933-1949 wit)
overall 34 percent 10-yea
survival; NYHA class III (B,C): 6:
percent 5-year, 30 percent 1C
year survival; NYHA class IV (D'
15 percent 5-year, 0 percent 1C
year survival.
Roy and Gopinath Series of 100 patients with mil
196822 (80 percent 8-year survival) c
severe (47 percent 8-yea
survival) stenosis.
Rapaport Series of 133 unselected patieni .
19757 with survivals of 80 percent at
years and 60 percent at 10 year)
Munoz et al. Surgical series with 58 symptl
197522 matic patients (NYHA classes
III, IV) treated medically. FortJ
five percent 5-year survival.
(continue
Rowe et al.
I96020
Olesen
196221
murmur. Clues to chronic, hemodynamically signiii-
cant aortic regurgitation include a widened pulse
pressure (greater than 60 mm/Hg) and concomitant
peripheral signs (de Musset’s sign: head bobbing; and
Quincke’s sign: subungual capillary pulsations),
diastolic pressure less than 70 mm/Hg (Traube’s sign:
femoral “pistol shots”), and reversed peripheral
diastolic blood flow (Duroziez’s sign: femoral
systolic/diastolic bruits with proximal/distal com-
pression). The pulse pressure:systolic pressure ratio is
greater than 50 percent. The chest x-ray shows left
ventricular enlargement and the electrocardiogram re-
veals systolic or diastolic overload left ventricular hy-
pertrophy (producing tall and upright T waves in the
precordial leads instead of the typical “strain” pattern
in V5.6 with systolic overload). The echocardiogram may
demonstrate left ventricular enlargement and hyper-
dynamic function (Figure 6). Spagnuolo et al. iden-
tified a triad of left ventricular enlargment, elec-
trocardiographic abnormalities (high voltage, ST-seg-
ment depression, and T-wave inversion), and abnormal
blood pressure (systolic pressure greater than 140
mm/Hg, diastolic pressure less than 40 mm/Hg, or
both) in 31 patients with rheumatic aortic regui-
tation.25 Thirty-three percent of the group either cd
or had congestive heart failure or angina within >e
year, 48 percent within two years, 65 percent vjh
three years, and 87 percent within six years of acqyi-
tion of the triad. Cardiac catheterization with contiji
aortography and quantitation of the regurgitant fci
tion is diagnostic (Figure 7).
The clinical impression that aortic regurgitation n
be well compensated for a long period has been derr l-
strated by several studies (Table). Bland and Whe:r
reported overall 10-year and 20-year survivals:)!
almost 62 percent and 44 percent, respectively, am $
87 young people with rheumatic aortic regurgitatio 26
Rotman et al. found an 80 percent 2.8-year surval
among 29 unoperated patients in a surgical stur5
Spagnuolo et al. defined a high-risk group of 31*
tients with a 6-year survival of 71 percent and a R-
risk group of 72 patients with only a single death < -t
the same period by the presence or absence of the t id
described above.25 Rapaport reported 75 percent 5-' tf
and 50 percent 10-year survivals among 35 unselecd
patients with chronic lesions.7 The pooled data f 11
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER
952
TABLE
Natural History of Valvular Lesions
Aortic Regurgitation Mitral Regurgitation
Bland and Wheeler Series of 87 children and adoles-
95726 cents with severe rheumatic re-
gurgitation followed 10 to 20
years. Forty-six patients
(1921-1931 series): Survivals of
76 percent, 61 percent, 50 per-
cent, 43 percent at 5, 10, 15, 20
years. Forty-one patients
(1931-1943 series): Survivals of
76 percent, 63 percent at 5, 10
years.
totman et al.
971 15
pagnuolo et al.
971 25
apaport
9757
chwarz et al.
982 17
Surgical series with 29 medically
treated patients. Survival of 80
percent at 2.8 years.
Series of 31 high-risk patients
with 71 percent 6-year survival
and 72 low-risk patients with 1
death in 6 years. Risk assigned
by the presence or absence of a
triad of left ventricular enlarge-
ment, electrocardiographic, and
blood pressure abnormalities.
Series of 35 unselected patients
with survivals of 75 percent at 5
years and 50 percent at 10 years.
Surgical series with 28 medically
treated patients. Eighty-seven
percent 5-year survival.
Wilson and Lim
195729
Rapaport
19577
Munoz et al.
197522
Series of 392 patients with pure
rheumatic regurgitation seen be-
tween 1916 and 1956, followed
from age 20 years until death or
the close of the study. Twelve
deaths in the group (1 en-
docarditis, 1 1 “other"). Overall
annual mortality rate over ages
20 to 52 years of 2.76/1000, not
significantly different from the
overall United States death rate
for the same.
Series of 70 unselected patients
with survivals of 80 percent at 5
years and 60 percent at 10 years.
Series of 102 unselected patients
with stenosis/regurgitation with
survivals of 67 percent at 5 years
and 33 percent at 1 0 years, worse
than the pure regurgitation
group.
Surgical series with 99 sympto-
matic patients (29 pure regurgi-
tation, 70 stenosis/ regurgita-
tion) treated medically. Forty-six
percent 5-year survival.
Hammermeister et al. Series of 36 medically treated pa-
197830 tients with survival probabilities
of 54 percent at 5 years and 22
percent at 10 years.
gnuolo et al. (high-risk group) and Rapaport are
jwn in Figure 2. The 5-year and 10-year survivals
76 percent and 62 percent, respectively. More re-
ady, Schwarz et al. had a 5-year survival of 87 per-
among 28 operative candidates who did not
i ergo surgery.17
ne problem in managing patients with chronic
: ic regurgitation is that they may develop ir-
■ rsible myocardial damage severely jeopardizing fu-
i surgical therapy while remaining asymptomatic,
i ddition, they may develop a rapid downhill course
b symptoms do occur. Guidelines for resolving the
nma of surgical timing are discussed in the next
; ion.
J RAL REGURGITATION
iitral regurgitation is present when the left atrium
f ives backward flow from the left ventricle during
"pie. The etiology of clinically isolated, severe,
bnic, pure mitral regurgitation was reviewed by
<jer et al. in 97 patients over the age of 30 years
nprgoing mitral valve replacement.27 The etiology
amitral valve prolapse in 62 percent, coronary ar-
i disease (papillaiy muscle dysfunction) in 30 per-
‘i. infective endocarditis on previously normal
1 ;s in 5 percent, and rheumatic in 3 percent. Thus,
i< etiology was nonrheumatie in 97 percent of the
* Tits in this recent series, strongly supporting the
ral consensus that rheumatic fever no longer is
;ajor cause of mitral regurgitation.
As with aortic regurgitation, mitral regurgitation
presents the left ventricle with a chronic volume over-
load. Patients usually develop fatigue and an insidious
loss of exercise capacity as early manifestations of con-
gestive heart failure. Self-limitation of activity can
further postpone the onset of symptoms. Eventually,
dyspnea on exertion and then at rest is followed by
frank failure. Onset of atrial fibrillation is the most
common cause of sudden decompensation.28 The
physical findings include a parasternal lift due to left
atrial expansion and a displaced, hyperdynamic left
ventricle. The first heart sound is diminished (de-
creased Ml) and there is a high-pitched, blowing,
apical holosystolic murmur radiating to the axilla and
back. This classical murmur was described primarily
in association with rheumatic lesions. The murmur of
mitral valve prolapse is midsystolic and that of cor-
onary arteiy disease often is late systolic. An S3 gallop
commonly is heard. The chest x-ray shows left atrial
and ventricular enlargement and the electrocardio-
gram demonstrates left atrial abnormality and systolic
or diastolic overload left ventricular hypertrophy. The
echocardiogram also may reveal left atrial enlargement
and a hyperdynamic left ventricle. Unlike the stenotic
lesions of the aortic and mitral valves, the regurgitant
lesions cannot be diagnosed on the basis of direct
echocardiographic visualization; they must be inferred
on the basis of indirect hemodynamic effects. Cardiac
catheterization with left ventriculography demonstrat-
ing regurgitant flow in systole to the left atrium is
81
—NUMBER 11— NOVEMBER 1984
953
Figure 6 — Left ventricular volume overload. This M-mode
echocardiogram was obtained from a patient with chronic
aortic regurgitation and demonstrates the appearance of left
ventricular (LV) volume overload. The left ventricle is enlarged
and hyperdynamic. A similar appearance is seen with chronic
mitral regurgitation.
diagnostic (Figure 8).
Survival data for mitral regurgitation are presented
in the Table. It should be emphasized that mitral re-
gurgitation is not invariably progressive.28 Due to the
long clinical course during which cardiac compensa-
tion is maintained, there are less data available on the
natural history of the disease. Kirkland and Pacifico,
reviewing the natural history of mitral valvular disease
in their surgical study, cited Olesen’s data for mitral
stenosis but could find “no comparable data for pa-
tients with mitral valvular incompetence" in 1973. 3
Wilson and Lim reported a series of 392 patients with
pure rheumatic mitral regurgitation seen between
1916 and 1956. The patients were followed from 20
years of age until death or the close of the study. There
were only 12 deaths in the group: one was attributed
to infectious endocarditis and the remaining 1 1 to
“other” noncardiac causes.29 Rapaport reported 80 per-
cent 5-year and 60 percent 10-year survival among 70
unselected patients with pure mitral regurgitation.7 He
also reported 67 percent 5-year and 33 percent 10-year
survival, respectively, in a group of 102 unselected pa-
tients with combined mitral stenosis/regurgitation.
Munoz et al. found a 46 percent overall 5-year survival
in a group of 99 patients comprised of 29 pure and
70 mixed lesions.22 Hammermeister et al. found
survival probabilities of 54 percent and 22 percent at
5 years and 10 years, respectively, for a group of 36
medically treated patients.30 Pooled data from the stud-
ies of Rapaport and Hammermeister et al. are shown
in Figure 2: the 5-year survival is 69 percent and the
10-year survival is 41 percent.
Patients with mitral regurgitation, like their
counterparts with aortic regurgitation, may develop
irreversible myocardial damage during the asymp-
tomatic phase of their disease. Due to favorable un-
loading of the left ventricle, patients with mitral regur-
gitation can sustain more cardiac dysfunction without
decompensation. However, when decompensation
necessitating surgical intervention does occur, the
postoperative course is less favorable than that with
aortic regurgitation.
PART 2
Part 2 will present recent surgical data and discuss
Figure 7 — Aortic regurgitation. This figure illustrates ar
teriogram in the left anterior oblique projection. A pig
catheter is present in the ascending aorta (single arri
There is severe aortic regurgitation with greater opacifica!
of the left ventricular chamber (double arrow) than the ac!|
A
Figure 8 — Mitral regurgitation. This figure illustrates ajf
ventriculogram in right anterior oblique projection. A pi il
catheter is present in the left ventricle (single arrow). Til
is severe mital regurgitation due to mitral valve prolapse, jif
left atrium (double arrow) is enlarged greatly and conU1
material can be seen refluxing into the pulmonary veil
the indications, timing, and hemodynamic impli
tions of surgery.
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nitral stenosis without surgery. Ten- and 20-year per-
:tives. Ann Intern Med 52:741-749, 1960.
t. Olesen KH: The natural history of 271 patients with
-al stenosis under medical treatment. Br Heart J
24:349-357, 1962.
22. Munoz S, Gallardo J, Diaz-Gorrin JR Medina O: In-
fluence of surgery on the natural histoiy of rheumatic mitral
and aortic valve disease. Am J Cardiol 35:234-242, 1975.
23. Goldschlager N, Pfeifer J, Cohn R Popper R Selzer A
The natural histoiy of aortic regurgitation. Am J Med
54:577-588, 1973.
25. Spagnuolo M, Kloth H, Taranta A Doyle E, Pasternack
B: Natural history of aortic regurgitation. Circulation
44:368-380, 1971.
26. Bland EF, Wheeler EO: Severe aortic regurgitation in
young people. N Engl J Med 256:667-672, 1957.
27. Waller BF, Morrow AG, Maron BJ, Del Negro AA Kent
KM, McGrath FJ, Wallace RB, McIntosh CL, Roberts WC:
Etiology of clinically isolated, severe, chronic, pure mitral re-
gurgitation: Analysis of 97 patients over 30 years of age
having mitral valve replacement. Am Heart J 104:276-288
1982.
28. Selzer A, Katayama F: Mitral regurgitation: Clinical pat-
terns, pathophysiology, and natural histoiy. Medicine
51:337-366, 1972.
29. Wilson MG, Lim WN: The natural histoiy of rheumatic
heart disease in the third, fourth, and fifth decades of life.
Circulation 16:700-712, 1957.
30. Hammermeister KE, Fisher L, Kennedy JW, Samuels S,
Dodge HT: Prediction of late survival in patients with mitral
valve disease form clinical, hemodynamic, and quantitative
angiographic variables. Circulation 57:341-349, 1978.
j
I
-31— NUMBER 11— NOVEMBER 1984
955
Benefits diuretics cannot offer . ..Once-daily inderal la
(propranolol hydrochloride) with its smooth 24-hour control of blood
pressure provides a high degree of patient acceptance without potas-
sium problems, plus the cardiovascular benefits of the world’s leading
beta blocker.
Experience no other beta blocker can match . . . Once-daily
INDERAL LA delivers the proven performance and safety profile of
INDERAL tablets — confirmed by millions of patients during 16 years
of clinical use. INDERAL LA should not be used in congestive heart
failure, sinus bradycardia, heart block greater than first degree, 01*
bronchial asthma.
Start with 80 mg once daily. . - Dosage may be increased to
120 mg or 160 mg once daily as needed to achieve additional control.
Please see next page for further details and brief summary of
prescribing information.
hi
80 120 160
mg mg mg
The appearance of INDERAL LA capsules
is a registered trademark of Ayers't Laboratories
[Ayerst j
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERALLA
(PROPRANOLOL HCI)
LONG ACTING
CAPSULES
80 120 160
mg mg mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma hall-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor ai d somewhat variable. INDERAL has
been shown to cause a small increase in serum potassii|rm'Concentration when usedljf the
treatment of hypertensive patients. St— .
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart-at
any given level of effort by blocking the catecholamine<iftdu©id increases in the hen rate,
systolic blood pressure, and the velocity and extent of myocardial dorttraction. Propranolol
may increase oxygen requirements by increasing left^eTtfnctllar fiber length erw-f'disistolic
pressure and systolic ejection period The net physiologic effect of beta-adrenorgtc qiock-ade
is usually advantageous and Is manifested during. exdrcise*ifey>de1ayed onset of pain and
increased work capacity.
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking tf|
prior to maior surgery is controversial It should be noted, however, that the impaired at>
the heart to respond to retlex adrenergic stimuli may augment the risks of general anes «
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor oi l
receptor agonists and its effects can be reversed by administration of such agents!
dobutamine or isoproterenol. However, such patients may be subject to protracted s|
hypotension. Difficulty in starting and maintaining the heartbeat has also been reporter
bctci blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent tl'j
pearance of certain premonitory signs and symptoms (pulse rate and pressure chanc |
acute hypoglycemia in labile insulin-dependent diabetes In these patients, it may bit
difficult to ad|ust the dosage of insulin.
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyrc j
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sym,i
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid functions
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have:
reported in which, after propranolol, the tachycardia was replaced by a severe brady,
requiring a demand pacemaker. In one case this resulted after an initial dose of H
propranolol.
PRECAUTIONS. General: Propranolol should be used with caution in patients with im
hepatic or renal function. INDERAL is not indicated for the treatment of hypertl
emergencies.
In dosages greater than required for beta blockade, INDERAL also exerts a quinidine
- - ne-if - _
or anesthetic-like membrane action which affects the cardiac action pote-t ai. ihe siuron- INDERAL is administered to a ntsifsing weenan
cance of the membrane action in the treatment of ^Wfhm^isSncerfaK jar"! :: PediatricVse: SaWy Wd effe ctivejps ir
"" ' ' ‘ ‘ ADVERSE REACTIONS. ^«»ad)Jrse effects have been mild and transient an
Beta adrenoreceptor blockade can cause reduction of intraocular pressure
should be told that INDERAL may interfere with the glaucoma screening test Withdraw
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart d
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such a:
pine should be closely observed if INDERAL is administered The added catechol;
blocking action may produce an excessive reduction of resting sympathetic nervous
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orth
hypotension
Carcinogenesis, Mutagenesis, Impairment ot Fertility: Long-term studies in animal
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stu
■tettwats aad naj& gmploytfig dosestqp^ J50 mg/kg/day. there was no evidence of sigr
dniq-in,: jcoU toxicin There were no drug-related tumorigemc effects at any of the c
nevellf Reproductive studies lb wjmals dig not show any impairment of fertility th‘
attributable to theKdrug.
Pregnancy ppgnapcy QalWbry CJNDERAL has been shown to be embryot
animal studies at CfSses about 10 tiries preafer than the maximum recommended humar
' n here are n<P8oeq3sPind weft-controlled studies in pregnant women INDERAL
be used during pregnancy only if the potential benefit justifies the potential risk to thi
Nursing Motfjmfc: INDERAL is excreted in human milk. Caution should be exercisei
The mechanism of the antimigraine effect of propranolol has not o««nestab shed Beta
adrenergic receptors have been demonstrated in J^afri
Beta receptor blockade can be useful in conditions iniarbilft because of pathologic or
functional changes, sympathetic activity is detrimental to the patient, lut there are also
situations in which sympathetic stimulation is vital FoPSxamplerm patients wimseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL.
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
i in children have not been established.
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and. in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
rarely«B|uired|h| withdm.va' of thetjiy
GadijiovadS9& (Drady^dia;-S0irg&stive heart failure; intensification of AV block
.tensioru paiesthesia ot hands: thrombocytopenic. purpura; arterial insufficiency, usuall
ftaynauoType '* Jm
Central Nervous Sysfem^Mieadedness; mental depression manifested by Ins
lassitude, weakness, fatiguenwersible mental depression progressing to catatonia
disturbances, hallucinations; an acute reversible syndrome characterized by disorient;
time and place, short-term memory loss, emotional lability, slightly clouded sensoriu
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, di
constipation, mesenteric arterial thrombosis, ischemic colitis
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocyt
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus ha:
reported.
Miscellaneous : alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male
tence, and Peyronie’s disease have been reported rarely. Oculomucocutaneous re
involving the skin, serous membranes and conjunctivae reported for a beta blocker (pr
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochlor
sustained-release capsule for administration once daily. If patients are switched from IN
tablets to INDERAL LA capsules, care should be taken to assure that the desired ther,'
effect is maintained INDERAL LA should not be considered a simple mg for mg subsl
INDERAL INDERAL LA has different kinetics and produces lower blood levels Retitrati
be necessary especially to maintain effectiveness at the end of the 24-hour dosing i
HYPERTENSION — Dosage must be individualized The usual initial dosage is
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage i
increased to 120 mg once daily or higher until adequate blood-pressure control is ac
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosag;
mg may be required The time needed for full hypertensive response to a given do1#
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDEi
once daily, dosage should be gradually increased at three to seven day intervals until o /'
response is obtained Although individual patients may respond at any dosage lej
average optimum dosage appears to be 160 mg once daily In angina pectoris, the va1
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a fey I
(see WARNINGS) fl
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDE
once daily. The usual effective dose range is 160-240 mg once daily. The dosage
increased gradually to achieve optimum migraine prophylaxis. It a satisfactory respon
obtained within four to six weeks after reaching the maximum dose, INDERAL LA
should be discontinued. It may be advisable to withdraw the drug gradually over a p
several weeks.
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group
limited to permit adequate directions for use
♦The appearance of INDERAL LA capsules is a registered trademark of Ayerst LaboM
891 ZtM
Nonallergic Bronchospasm (e.g,, chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
958
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
NDIUM- 111 -OXINE-LABELED
,eukocyte Imaging
'red M. Palace, m.d., and Raymond F. Crystal, m.d., Morristown*
I
n the postoperative period , it is difficult to determine the location
fan inflammatory process for purpose of drainage. Fifteen
yatients participated in a study in which injection of the patient's
twn white blood cells labeled with indium- 1 1 1 -oxine was used to
iemonstrate localizedfoci of inflammation.
In the evaluation of the patient
who has developed signs and
symptoms of infection after ab-
i ninal surgery, a surgeon has few effective modalities
> liagnosis. A chest x-ray, a urinalysis, and an evalu-
nn of the incision for infection are utilized.
'T scanning as the first step in screening is not cost
I 'Ctive. It is most helpful when a relatively small area
£ o be scanned, since individual tomographic slices
m the diaphragm to the pubis at centimeter inter-
r 5 are high in cost, high in radiation, and low in
r ds.1 It is difficult, if not impossible, to differentiate
) ween a noncontrast filled bowel loop and an abscess
) these computer-created images,
jfltrasonography also is limited in value by the fact
I t postoperative patients show a reactive (adynamic)
Ijjis and bowel gas is an effective barrier to ultra-
ographic evaluation. Scanning the patient after an
i 'avenous injection of gallium 67 has been used for
) poses of localization of an abscess. Disadvantages
t (1) the slow nature of the procedure, i.e. gallium
bst clear the soft tissues before localization of an
i cess can be made, usually in 36 to 48 hours; (2) the
Gerial is excreted through the gastrointestinal tract
1 1 therefore the colon (especially the right colon) is
ialized unless massive efforts to cleanse the colon
M made; and (3) radiogallium is taken up in the
ural line itself (probably by histiocytes there),
new modality of diagnosis now is avail-
,
'• 81— NUMBER 11— NOVEMBER 1984
able — injection of the patient’s own indium- 1 1 1-oxine-
labeled white blood cells (WBC). This technique can be
used to localize foci of inflammation and infection.
METHODS
Fifteen patients at Morristown Memorial Hospital
participated in a phase III clinical evaluation of in-
dium-1 1 1-oxine-labeled WBC as approved by the Hos-
pital’s Institutional Review Board. Fifty cc of blood was
withdrawn in a heparin-coated syringe and sent to a
commercial laboratory** where the patient’s WBC were
labeled using a technique approved by the Amersham
Corporation and the Food and Drug Administration.9
The tagged WBC (containing approximately 500 uc of
radioindium) were returned to the hospital within
three hours; the patient was injected with these cells
and imaging of the patient was performed 4 to 18
hours later using either a 61 tube (General Electric)
Maxicamera or a 37 tube Gamma Camera (Picker Cor-
poration). Images to include the top of the head down
to below the hips in both the anterior and posterior
positions were taken. The extremities were imaged if
*Dr. Palace is Chief, Section of Nuclear Medicine, and Dr.
Crystal is Attending Surgeon, Colon-Rectal Surgery. Mor-
ristown Memorial Hospital. Correspondence may be ad-
dressed to Dr. Palace, Morristown Memorial Hospital, 100
Madison Avenue, Morristown, NJ 07960.
**Syncor. Inc., Fairfield, NJ.
959
cliniceilly indicated and 300,000 counts per image were
collected. The following are representative case his-
tories.
CASE REPORT 1
A 72-year-old female was hospitalized with dyspnea
requiring intubation, ventilator support, and steroid
therapy. Ten days later, she underwent antrectomy,
vagotomy, and gastroduodenostomy for a bleeding
duodenal ulcer. The bleeding persisted postoperativelv
and a subtotal gastrectomy and gastrojejunostomy
were performed. Three days later, she developed pneu-
monitis which was treated with tobramycin and clin-
damycin intravenously. In spite of antibiotics, she
maintained a persistent temperature elevation to
38.6°C and a leukemoid reaction with WBC count of
44.800. Gallium scanning showed increased uptake in
the left lung (consistent with the patient's left lower
lobe pulmonary infiltrate) and increased uptake in the
left flank (Figure 1 ). CT scan of the abdomen (after oral
and intravenous contrast material) demonstrated no
abnormal collections. Indium-111 WBC study one
week later demonstrated abnormal uptake in both
lower lobes and throughout the entire colon (Figure 2).
Bv this time the patient developed diarrhea and was
passing ten liquid stools per day. The stool culture was
negative for salmonella shigella and other enteric
pathogens. Three stools were positive for Clostridium
difficile toxin. Colonoscopy to 50 cm revealed multiple
whitish plaques throughout, consistent with
pseudomembranous colitis. Treatment with van-
comycin was begun and within one week the diarrhea
had stopped and the patient’s WBC count had fallen
to 13,600.
This seriously ill elderly patient, who received a
number of antibiotics including clindamycin, was at
high risk for the development of pseudomembranous
colitis. Nevertheless, various symptoms and signs
(diarrhea abdominal pain, fever, leukocytosis, and, in
some cases, megacolon) may make diagnosis difficult,
particularly in patients who have undergone
gastrointestinal surgery.2 Traditionally, the most re-
liable diagnostic tools were considered to be the proc-
toscopic examination, barium contrast study of the
colon, and biopsy.3
The indium-labeled WBC scan may evaluate patients
rapidly (six hours) with an acute abdomen which is
fulminant and in which intubation ol the colon or the
hydrostatic pressure of an enema may be hazardous,
and with colitis which may be differentiated from
other causes of diarrhea by a noninvasive method be-
cause of the severity and extent of the inflammation.
The indium-labeled WBC scan also is an accurate
method for assessing the patient with acute ulceration
and Crohn's disease.4
CASE REPORT 2
An 82-year-old white female underwent Hartmann
resection of the left colon with a distal transverse co-
lostomy on May 8, 1983, for acute and chronic
diverticulitis with partial colonic obstruction. Post-
operativelv. she developed a wound infection due to
Pseudomonas aeruginosce E. coli. and enterococcus.
On May 23, 1983, an indium-1 1 1 -labeled WBC scan
Figure 1 — Anterior view of abdomen: gallium scan. Note i
Hum uptake in the liver and colon as usually seen (case rejl
1).
Figure 2— Anterior view of abdomen and pelvis: incur
study. Note normal uptake in the liver and spleen anc'b
normal uptake in the colon demonstrating the pseudor i'
branous colitis (case report 1).
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER
960
Figure 4— Anterior view (18 hours) indium scan. Note ab-
normal uptake in the suture line and in the left lower quad
rant representing the fistula and normal uptake in the liver
and spleen (case report 2).
This information may affect the choice between
surgical and percutaneous drainage.7
CASE REPORT 3
A 26-year-old white female, whose Crohn's disease
was first diagnosed at age 13, underwent resection of
the terminal ileum and cecum at age 17. She subse-
quently had recurrent exacerbations of weight loss,
fever, anorexia and diarrhea. In July 1982, the
diagnosis of pregnancy was associated with fever, 18
to 20 pound weight loss, pain in the right lower quad-
rant, and a mass. Sigmoidoscopy revealed many shal-
low serpiginous ulcers of the mucosa of the rectum.
In November 1982, she was admitted to Morristown
Memorial Hospital and the preganancy was termin-
ated. A small bowel x-ray study showed a collection of
barium, within an abscess cavity in the right upper
quadrant, believed to have extravasated through a fis-
tulous tract from the small bowel. There was complete
involvement of the large bowel with what appeared to
be granulomatous colitis. On November 30. she under
went a diverting ileostomy and drainage of a right
retroperitoneal abscess. Postoperativelv she was
961
gure 3 — Anterior view gallium scan (48 hours) demonstrat-
g the abnormal (but weak) uptake in the left lower quadrant
lase report 2).
as performed. An abnormal collection of radionuclide
insistent with a large abscess was seen in the left
teral abdomen extending from the inferior margin of
ie spleen into the pelvis. There also was abnormally
creased uptake of radionuclide extending from the
phoid to the pubis consistent with an infected mid-
pe abdominal incision. On May 26, 1983, a barium
iiema study through the colostomy demonstrated a
rge abscess cavity in the left gutter which filled with
mum presumably through a fistulous communica-
pn. A sump drain was placed in this abscess cavity
id cultures grew Pseudomonas and E. eoli (Figures
to 6).
Intra-abdominal abscess following colonic surgery is
)t rare. In a study of 231 consecutive colonic oper-
ions, four patients developed intra-abdominal
:>scesses.5 Unrecognized and untreated, intra-ab-
)minal abscesses may lead to additional complica-
ms and death. Identification and localization of such
i abscess by a noninvasive technique is highly de-
rable yet not always easily accomplished. The ac-
iracy of indium-labeled WBC scan for this purpose
is been well documented.6 A particular benefit of
ich a noninvasive test is its ability to identify the
umber of purulent collections in a particular patient.
JL. 81 -NUMBER 11 -NOVEMBER 1984
Figure 5 — Posterior view of indium study showing large
intra-abdominal and intrapelvic abscess (case report 2).
treated with clindamycin and tobramycin and was
afebrile until December 6, 1982, when her temperature
rose to 38.3°C. Progressive anemia required trans-
fusion of nine units of packed cells between December
4 and December 9. She had recurrent fever and on
December 21, 1982, an indium-labeled WBC scan
showed abnormal uptake in multiple loops of small
bowel in the right mid-epigastrium consistent with an
active granulomatous process (Figure 7). A huge area
of abnormal uptake filled much of the left side of the
pelvis, and extended up to the spleen. This was
thought to represent phlegmon or abscess involving
the distal descending colon and rectosigmoid. White
blood count at that time was 16,500. CT scan of the
abdomen demonstrated a large mass of loculated fluid,
thought to represent the phlegmon as previously de-
scribed (Figures 8 and 9). A barium enema through the
rectum demonstrated the devitalized colon to be ap-
propriately narrow so that the abnormal uptake on the
indium scan and the CT study could not represent an
inflamed colon. On December 23, 1982, the patient
underwent an incision and drainage of an infected
intraperitoneal hematoma. By Januaiy 5, 1983, she
was afebrile with a pulse of 80 and a white blood count
of 10,600. A subsequent indium-labeled study showed
resolution of the abdominal/pelvie mass previously de-
Figure 6— Anterior posterior view of barium enema illustrai
ing a catheter in the colostomy and contrast material fillin
the peritoneal abscess (case report 2).
scribed but the abnormal small bowel and colonic uj
take remained.
This case demonstrates a variety of radiological me
dalities used to diagnose intra-abdominal and retre
peritoneal abscesses. The first abscess was demor
strated by a small bowel series, which confirmed
fistulous connection between the bowel and absees
cavity. An infected hematoma was first localized by th
indium study and further documented by the C
study. The resolution of the abscess was well demor
strated by repeat indium scanning which also demon
strated that the tagged leukocytes will be taken up b
an actively inflamed colon. This principle has beei
applied to the differentiation of the pancreatic absees
from pancreatic pseudocyst using indium- 1 1 1-labelei
leukocytes (Figures 7 to 9). 8
DISCUSSION
Indium- 1 1 1-autologous white blood cells have beei
used for localization of abscesses, fistulae, and os;
teomyelitis for many years first having been used fo
this purpose in 1976. 9 The radionuclide is deposited
wherever white cells are sequestered which explain
the distribution of the radioindium in the bone mar
row, in the liver, and in the spleen. Areas of focal infec
tion usually are demonstrated well. The materia
usually is not deposited in normal bowel and has beei;
shown to have clinical utility in the evaluation of pa'
tients with granulomatous and ulcerative bowel dis;
ease.4 False positive studies are found in cases o;
swallowed leukocytes (e.g. sinusitis, rhinitis, en
dotrachial tubes, nasogastric tubes), accessory spleens:
and transplant rejections.10
False negative studies occur in patients with longj
standing abscesses which perhaps do not have an ade|
quate blood supply and, therefore, lack a mechanism
for the white cells to be sequestered there. Similarly;
in an area of osteomyelitis where the periosteum i-‘i
tightly adherent and where there is a choking otf o
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
962
R L
Igure 7— Anterior view of abdomen and pelvis indium study
Hl8 hours). Note abnormal uptake in the left lower quadrant
epresenting the infected hematoma. Note abnormal uptake
ight lower quadrant representing abnormal small bowel (re-
gional enteritis) (case report 3).
ie blood supply, there is an occasional false negative
fudy. The sensitivity and specificity of the indium
fudy is reported to be 95 percent and 97 percent,
fespeetively. 1 1
Indium- 1 1 1-WBC imaging is at least as sensitive as
allium in imaging and has far greater specificity due
(jib the fact that there is no normal bowel uptake, which
sj> gallium’s major disadvantage. This study will be of
ignificant aid to the physician in the evaluation of
atients with occult inflammatory disease especially
/hen many of the paperwork obstacles to wider utiliza-
lon have been relieved.
REFERENCES
1. Karsell PR II, O’Connell MJ: Computer tomography in
eareh of cancer of unknown origin. JAMA 248:340-343,
982.
2. Dowel VR Jn Antibiotic associated colitis. Hosp Prac 75:
979.
| 3. Tedesco FJ, Stanley RJ, Alpers DH: Diagnostic features
OL. 81— NUMBER 11— NOVEMBER 1984
Figure 8 — Initial image of CT scan demonstrating contrast
materia] in the defunctionalized colon (case report 3).
CF NORMAL I M 1 = 5 1 2
SLC THK 10 C E H 0
MAT 512 USP 1/2 WIN 353
TILT . 1 POST D I A 4 0.3
#4071 1 7 SCAN ' t 4
TBL -280
Figure 9— Pelvic CT scan demonstrating huge pelvic mass
subsequently drained (ease report 3).
of clindomyein-associated pseudomembranous colitis. N Engl
J Med 290:841, 1974.
4. Stein DT, Gray GM, Gregory PB, Anderson M, Goodwin
DA, MeDougall IR- Location and activity of ulceration and
Crohn's colitis by indium 111 leukocyte scan.
Gastroenterology 84:388-393, 1 983.
5. Crystal RF, Chang P: The surgeon, the surgery, the pa-
tient, and the disease; factors complicating colonic surgery.
Ann Surg 181:9-14, 1975.
6. Coleman RE, Black RE, Welch DM, Maxwell JG: In-
dium-11 1 labeled leukocytes in the evaluation of suspected
abdominal abscesses. Am J Surg 118:273, 1983.
7. Aeder MI, et al.: Role of surgical and percutaneous
drainage in the treatment of abdominal abscesses. Arch Surg
118:273, 1983.
8. Bicknell TA. Kohatsu, S, Goodwin DA: Use of indium- 111
labeled autologous leukocytes in differentiating pancreatic
abscess from pseudocyst. Am J Surg 142:312, 1981.
9. Siegel AW, Amot RN. Thakur ML, et al.: Indium-ill-
labeled leukocytes for localization of abscesses. Lancet
2:1056, 1976.
10. Coleman, RE, Walsh, E: Possible pitfalls with clinical
imaging of indium- 1 1 1 leukocytes: concise communication.
J Nucl Med 21:122. 1980.
11. McDougal IR, Goodwin DA: Editor's correspondence.
Arch Int Med 142:1407, 1982.
963
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, INDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets—
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
LONG ACTING
CAPSULES
Ayerst
The appearance of
INDERAl LA
capsules is a registered
trademark of
Ayerst L aboratories
ONCE- DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE ,
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERALLA
2CC
LONG ACTING
CAPSULES
80
mg
120
mg
160
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL* LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents tor available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect. INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it read|usts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and somewhat variable INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine inducer.1 increases in 'he hear* rate ,
systolic blood pressure, and the velocity and extent of 'nyoc.iidiai contraction Propranolol,,
may increase oxygen requirements by increasing left ventricular fifijar length, end atastolicl
pressure and systolic election period The net physiologic effect of beta adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity
In dosages greater than required for beta blockade, INDERAL also exerts a quimdine-hke
or anesthetic-like membrane action which affects the cardiac action potent a 'he signifi-
cance of the membrane action in the treatment of arrbyfbrftias ispnee^n 3|
The mechanism of the antimigraine effect of propranolol has ngEpeen established,
adrenergic receptors have been demonstrated i ri the piafvissets of the brain.
Beta receptor blockade can be useful in conditions in whicht"bepause of pathologifc or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For example in patients wftWseverely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of AV block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subiect to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician’s advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking th;
prior to maior surgery is controversial. It should be noted, however, that the impaired ab I
the head to respond to reflex adrenergic stimuli may augment the risks of general anesl;|
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of
receptor agonists and its effects can be reversed by administration of such agents,
dobutamine or isoproterenol However, such patients may be subject to protracted sj
hypotension Difficulty in stading and maintaining the headbeat has also been repodei
b©t3 blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent th
pearance of cedain premonitory signs and symptoms (pulse rate and pressure chang
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask cedain clinical signs of hypedhyroi
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symji
of hypedhyroidism, including thyroid storm. Propranolol does not distod thyroid function
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have
repoded in which, after propranolol, the tachycardia was replaced by a severe bradyq
requiring a demand pacemaker. In one case this resulted after an initial dose of
propranolol
PRECAUTIONS. General: Propranolol should be used with caution in patients with imp
hepatic or renal function. INDERAL is not indicated for the treatment of hyperte!
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pe
should be told that INDERAL may interfere with the glaucoma screening test Withdraw:
lead to a return of increased intraocular pressure
Clinical Laboratory Tests . Elevated blood urea levels in patients with severe head dis
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered The added catechola
blocking action may produce an excessive reduction of resting sympathetic nervous a
which may result in hypotension, marked bradycardia, vedigo, syncopal attacks, orodhc
hypotension
Carcinogenesis, Mutagenesis, Impairment ot Fertility: Long-term studies in animals
been conducted to evaluate toxic effects and carcinogenic potential In 18-month stuc
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sign
drug-induced toxicity There were no drug-related tumorigenic effects at any of the dr
levels, Reproductive studies in animals did not show any impairment of fertility tha
attributable to the drug
Pregnancy Pregnancy Category C I INDERAL has been shown to be embryotc
...animal studies aldoses about 10 times greater than the maximum recommended human
Tfiere are no adequate and well-controlled studies in pregnant women INDERAL s
be used during, pregnancy only if the potential benefit justifies the potential risk to the
Nursing ftUfps: INDERAL is excreted in human milk. Caution should be exercised
INDERAL triminis’ered to a nursing woman
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and
tfely required the withdrawal of therapy
Cardiovascular: bradycardia, congestive heart failure; intensification of AV block;
hsion; paresthesia Of hands; thrombocytopenic purpura, arterial insufficiency, usually
“PfaynaudType. '****' jm
Central Nervous System: liqtiibeasieriness mental depression manifested by insc
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia
disturbances; hallucinations: an acute reversible syndrome characterized by disorientat
time and place, short-term memory loss, emotional lability, slightly clouded sensoriun
decreased performance on neuropsychometrics.
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, dia
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with £
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocyte
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has
reported
Miscellaneous alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male
fence, and Peyronie's disease have been reported rarely Oculomucocutaneous rea!
involving the skin, serous membranes and conjunctivae reported for a beta blocker (praj
have not been associated with propranolol.
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloric
sustained-release capsule for administration once daily. If patients are switched from INC;
tablets to INDERAL LA capsules, care should be taken to assure that the desired thera
effect is maintained INDERAL LA should not be considered a simple mg for mg substit
INDERAL INDERAL LA has different kinetics and produces lower blood levels RetitratiC;
be necessary especially to maintain effectiveness at the end of the 24-hour dosing in
HYPERTENSION — Dosage must be individualized. The usual initial dosage is t|
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage it
increased to 120 mg once daily or higher until adequate blood-pressure control is ach)
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage;
mg may be required The time needed for full hypertensive response to a given dos!
variable and may range from a few days to several weeks. ,
ANGINA PECTORIS — Dosage must be individualized. Starting with 80 mg INDEE’
once daily dosage should be gradually increased at three to seven day intervals until op)
response is obtained Although individual patients may respond at any dosage lev/
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the valij
safety of dosage exceeding 320 mg per day have not been established.
If treatment is to be discontinued, reduce dosage gradually over a period of a few
(see WARNINGS).
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDEFj
once daily The usual effective dose range is 160-240 mg once daily The dosage m
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response
obtained within four to six weeks after reaching the maximum dose, INDERAL LA tl
should be discontinued It may be advisable to withdraw the drug gradually over a pe|
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group
limited to permit adequate directions for use.
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Labor
883
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
966
THE JOUFINAL OF THE MEDICAL SOCIETY OF NEW JER9
Pharmacological Basis of Therapeutics
nsulin-Like Growth Factors*
Margaret A. Brostrom, ph.d., piscataway**
Insulin and the insulin-like growth J actors IGF-I and IGF-II belong
to a family of growth-promoting polypeptides that share a con-
siderable degree of structural similarity . Members of the family
hf insulin-like growth factors have their own receptors but some
polypeptides crossreact with receptors for other family members.
Insulin and insulin-like growth
factors belong to a family of
biologically active growth-
fomoting polypeptides that share a considerable
cgree of similarity in primary and secondary struc-
tre and may have a common evolutionary origin.1
his family includes insulin-like growth factor I (IGF-
1 which also is called somatomedin C and is homolo-
t us to proinsulin, insulin-like growth factor II (IGF-
I which also is homologous to proinsulin, relaxin, and
■2 more distant relative, nerve growth factor. These
fctors are single chain polypeptides of 7,000 to 9,000
j)lecular weight; they are acid-soluble, acid and heat
Sable, and inactivated by thiols.2 IGF-I and IGF-II are
[;ntical at 45 of 73 amino acid positions examined.
Ith factors have been isolated from human plasma,
Ifer, and liver-derived cells and are bound in serum
cparendy by a complex carrier system.3 Concentra-
t ns of IGF-I and IGF-II in human plasma appear to
t regulated by growth hormone in accord with the
■pothesis that these substances serve as mediators
c growth hormone action. Like insulin, both
Sjbstances stimulate glucose oxidation and
f agenesis in adipose tissue; stimulations, however,
a - not affected by antibodies to insulin and are much
Sailer than those produced by insulin.2 In cartilage,
;se factors enhance sulfate incorporation into
cosaminoglycans; in cartilage, muscle, and
roblasts, they stimulate RNA, DNA, and protein syn-
VL. 81— NUMBER 11— NOVEMBER 1984
thesis; and, when applied to certain cultured cell types
they promote cell multiplication. Many of the actions
previously attributed to growth hormone now are
recognized to be mediated by IGF-I and IGF-II.4 Thus,
a role for these factors in the control of growth is
favored strongly by the available evidence.
It has been proposed that insulin, IGF-I, and IGF-II
exert their metabolic effects via insulin receptors and
their growth-promoting effects through IGF receptors.5
Knowledge regarding insulin and IGF receptors recent-
ly has been reviewed.6 Each insulin-like factor has its
own receptor but some polypeptides crossreact with
lower affinity with receptors for the other polypeptides.
IGF-I, for example, binds to the receptor for IGF-II with
a relatively high affinity, and vice versa In contrast,
both peptides bind to the insulin receptor with low
affinity. Insulin binds to the IGF-I receptor with poor
*This article, fifth in a series, prepared under the leadership
of Bruce McL. Breckenridge, M.D., Chairman, Department of
Pharmacology, UMDNJ-Rutgers Medical School, is a brief re-
view of recent advances in pharmacology and related pre-
clinical sciences which will help readers to understand the
actions of new and established therapeutic agents. The re-
views do not consider indications for specific drugs, incom-
patabilities, or dosage forms, which can be found in the AMA
Drug Evaluations, 5th Edition, 1983.
**From the Department of Pharmacology, UMDNJ-Rutgers
Medical School. Correspondence may be addressed to Dr. M.
Brostrom. UMDNJ-Rutgers Medical School, P.O. Box 101.
Piscataway, NJ 08854.
967
affinity and has little or no affinity for the IGF-II recep-
tor. Proinsulin has a weak affinity for the relaxin recep-
tor. Such findings imply similarities among receptors
for insulin-like factors, and similarities indeed have
been found. Receptors for IGF-I and IGF-II have been
identified and characterized. The IGF-I receptor has a
subunit structure which is remarkably similar to that
of the insulin receptor. It is a glycoprotein of approx-
imately 350 killidaltons and, when subjected to elec-
trophoresis without prior reduction, high molecular
weight species with mobilities similar to unreduced
forms of insulin receptors are observed. After complete
reduction, a species of 135 killidaltons, which cor-
responds to the a subunit of the insulin receptor, is
present. In some studies, a second species of 90
killidaltons has been observed; this species cor-
responds to the 13 subunit of the insulin receptor. The
/? subunits of both receptors, in contrast to their a
subunits, are only weakly labeled in affinity labeling
studies. The IGF-I receptor, like the insulin receptor,
has been shown to exist as a disulfide-linked heter-
otetramer with a subunit structure (cv/3) 2 . Monoclonal
antibodies have been produced which recognize pref-
erentially either insulin receptors or IGF-I receptors.6
However, each antibody erossreacts with both recep-
tors showing clearly that the two receptors are related
immunologically.
The IGF-II receptor appears structurally to be some-
what different from both the insulin receptor and the
IGF-I receptor. Studies are consistent with a single
polypeptide that is not linked through disulfide bonds
to other membrane proteins. The IGF-II receptor has
a molecular weight of approximately 260,000 and ap-
pears to be held together by intrachain disulfide
bonds. Investigators in the field are puzzled as to why
IGF-II receptors should be so different. However, a
200,000 molecular weight peptide, labeled by prior ex-
posure of cells possessing insulin receptors to radio-
active amino acid and precipitated by antibody to the
insulin receptor, has been identified and hypothesized
to be a biosynthetic precursor of the insulin receptor.7
It is possible that proteolytic processing of this
precursor could generate the a and (3 subunits. If this
is the case, then the 200 killidalton precursor would
be homologous to the single polypeptide IGF-II receptor
which would possess a and (3 subunits in a single
linear sequence. The insulin and IGF-I receptors are
anticipated to undergo posttranslational modi-
fications through which two precursor molecules
would be linked by disulfide bonds and then cleaved
to generate a tetramer. By contrast, the IGF-II receptor
is expected to be resistant to such post-translational
processing.
Extensive experimentation into the mechanism of
insulin action 689 indicates that occupation of insulin
receptors may result in (a) phosphorylation of tyrosine
residues on the receptor through the activation of a
protein kinase intimately associated with the receptor,
(b) generation via proteolytic events of a chemical
mediator, (c) receptor-mediated internalization of in-
sulin, and (d) receptor “down-regulation.” Whether
comparable events follow the binding of IGF-I or IGF-
II to their specific receptors remains to be demon-
strated.
Two published studies are consistent with the con-
cept that alterations in insulin-like growth factor cor
centrations occur during disease. In one study,
serum concentrations of IGF-I and IGF-II were di
termined for 80 adult patients with diabetes and 6
control subjects. The rationale for conducting tl
study was the long-recognized association of pituitai
growth hormone with the development of diabetic re
inopathy, thickening of capillary basement men
branes, and microvaseular complications. Coneentr.
tions of IGF-I in serum from patients with type I (ir
sulin-dependent) diabetes were significantly high*
than normal and higher than serum concentrations <
this factor in type II (noninsulin-dependent) diabete
The serum concentrations of IGF-II, however, did n<
appear to be altered in type I disease and were lowi
than normal in type II diabetes. The most strikir
finding was a gross elevation of IGF-I in diabetic adul
with rapidly progressing proliferative disease of tl
retina It was postulated that high levels of IGF-I migl
contribute to or cause the accelerated phase of d
terioration and, indeed, the capacity of IGF-I to stim
late cell multiplication is compatible with thj
hypothesis. Other interpretations are possible, hoi
ever, and the study has been criticized." 12 Nonetheles
further research in this area is warranted. I
vestigators of the study claim that, at the minima
IGF-I levels can serve to identify patients at risk f
rapid deterioration of vision and, therefore, may 1
useful for selecting patients for more vigorous insul
therapy or an alternate form of therapy.
Actions attributed to growth
hormone are recognized to
be modified by IGF-I and
IGF-II.
Children with craniopharyngiomal tumors oft
exhibit delayed growth and short stature secondary
impaired hypothalamopituitary function. Po;
operatively, the impaired growth rate frequently i
mains low. Recently, 19 children with era!
ophaiyngioma and demonstrated growth hormone c
ficiency were examined for IGF concentrations as w
as for levels of insulin and prolactin.13 Patients we:
placed into three groups based on their rate of grow
during the first postoperative year. Children in gro1
A showed excessive growth, in group B normal grow
and in group C decreased growth. The children in
three groups had low or undetectable growth hormo
levels. Measurements of serum IGF levels, however,
vealed differences among the three groups which coi
explain the differences in growth rate. Patients
group C presented with a classic picture
hypopituitarism and exhibited low serum concent
tions of IGF-I, - prolactin, and insulin. On the otl
hand, IGF-I levels appeared to be normal and prolacj
to be elevated in most patients in groups A and B. Sui
results are compatible with the notion that IGF-I i:
growth mediator. Since all patients exhibited low
absent growth hormone, it was proposed that hi
prolactin levels shown by patients in groups A anci
were responsible for generation of normal amounts '
IGF-I. IGF-II levels were normal in most patients in
968
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS'
ree groups implying that generation of IGF-II is less
■pendent on growth hormone or high circulating
olactin than is IGF-I. Insulin levels were low in
oups B and C but were elevated in group A It was
ncluded that in group B normal IGF-I levels in
sponse to elevated prolactin permitted normal
owth whereas the excessive growth in group A pa-
ints may have been caused by the action of insulin,
iesent in excessive concentrations, at IGF-I receptors,
le children in group C with both low insulin and low
F-I levels would be predicted, therefore, to fail to grow
,>rmally.
INCLUSION
Further studies of the role of insulin-like factors and
eir receptors in growth regulation undoubtedly will
suit in a better understanding of the importance of
ese factors in disease. With such advances should
me new or better approaches to the pharmacologic
ntrol of diabetic retinopathy, growth hormone defi-
?ncy, or other disorders characterized by abnormal
tawth.
DFERENCES
. Blundell TL, Humbel RE: Hormone families: Pancreatic
rmones and homologous growth factors. Nature 287: 781,
SO.
1. Rechler MM, Nissley SP, King GL, Moses AC, Van Ob-
■ghen-Schilling E, Romanus JA, Knight AB, Short PA
lite RM: Multiplication stimulating activity (MSA) from the
L 3A rat liver cell line: Relation to human somatomedins
and insulin. J Supramol Struct Cell Biochem 15: 253, 1981.
3. Zapf J, Rinderkneeht E, Humbel RE, Froesch ER
Nonsuppressible insulin-like activity (NSILA) from human
serum: Recent accomplishments and their physiologic im-
plications. Metabolism 27: 1803, 1978.
4. Zapf J, Sehoenle E, Froesch ER Insulin-like growth fac-
tors I and II: Some biological actions and receptor binding
characteristics of two purified constituents of nonsup-
pressible insulin-like activity of human serum. Eur J
Biochem 87: 285, 1978.
5. Kahn CR Baird KL, Flier JS, Grunfeld C, Harmon JT,
Harrison LC. Karlsson FA Kasuga J, King GL, Lang UC,
Podskany JM, Van Obberghen E: Insulin receptors, receptor
antibodies, and the mechanism of insulin action. Rec Prog
Hormone Res 37: 477, 1981.
6. Jacobs S, Cuatreeasas P: Insulin receptors. Ann Rev
Pharmacol Toxicol 23: 461, 1983.
7. Deutseh PJ, Wan C, Rosen OM, Rubin CS: Latent insulin
receptors and possible receptor precursors in 3T3— LI
adipocytes. Proc Natl Acad Sci USA 80: 133, 1983.
8. Strauss DS: Effects of insulin on cellular growth and
proliferation. Life Sci 29: 2131, 1981.
9. Lamer J, Cheng K, Schwartz C, Kikuchi K, Tamura S,
Creaey S, Dubler R Galasko G, Pullin C, Katz M: Insulin
mediators and their control of metabolism through protein
phosphorylation. Rec Prog Hormone Res 38: 511, 1982.
10. Merriman TJ, Zapf J, Froesch ER Insulin-like growth
factors. Studies in diabetics with and without retinopathy. N
Engl J Med 309: 527, 1983.
1 1. Carroll PB: Insulin-like growth factors and diabetic ret-
inopathy. N Engl J Med 309: 1649, 1983.
12. Kombluth A Insulin-like growth factors and diabetic
retinopathy. N Engl J Med 309: 1649, 1983.
13. Bucher H, Zapf J, Torresani T, Prader A Froesch ER
Illig R Insulin-like growth factors I and II, prolactin, and
insulin in 19 growth hormone-deficient children with ex-
cessive, normal, or decreased longitudinal growth after oper-
ation for craniopharyngioma N Engl J Med 309: 1 142, 1983.
(
>. 81 -NUMBER 1 1
NOVEMBER 1984
969
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972
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER W
>ediatric Briefs
Richard H. Rap kin, m.d., Franklin C. Behrle, m.d., Shyan C. Sun, m.d., Newark*
Pediatric Briefs are abstracted from the Newsletter, a continuing
medical education project of the Department of Pediatrics,
UMDNJ-New Jersey Medical School and the Children’s Hospital
of New Jersey.
:yden JJ: Com starch, Candida albicans, and
aper rash. Pediatr Dermatol 1:322, 1984.
Growth of Candida was not enhanced by com
arch or talcum powder. Both com starch and talcum
duced friction. ‘The use of these materials as part
the overall management of diaper dermatitis ap-
:ars to be both safe and rational.”
Com starch, for diaper rash, is cheap, universally
ailable, and works well. Baby powder containing
lcum costs more and smells good. Com starch is
ore absorbent, too. Whether com starch is indeed
‘tter than talcum has not been studied. Whether
ther is needed at all also is not known,
mkey RJ, et al.: Visual hallucinations in children
ceiving decongestants. BrMedJ 288:1369, 1984.
Three children developed visual hallucinations after
king usual doses of Actifed®. Other dmgs or toxins
ire not found. The active ingredient, pseudo-
hedrine, was implicated.
Side effects of virtually useless dmgs are very im-
rtant to note. Since the drug has limited or no ben-
' it, the cost to benefit ratio depends upon no side
1 ects. If benefits are clear, then occasional mild side
ects may be tolerable.
The authors conclude: “Ask about decongestant
■age when faced with a child presenting with visual
illucinations.”
oilman ST: The decline of rheumatic fever (RF):
bat impact on our management of pharyngitis. Am
Dis Child 138:426, 1984.
In the 1920s to 1950s, RF was the major cause of
death in the age group 5 to 19. There has been a major
decline in incidence (we now see one to two cases per
year in our hospital compared to one per month or
more in 1970) and the decline is unexplained. On the
other hand, throat symptoms are now the third most
common visit to a physician, throat cultures cost $10
to $12, and some patients with positive throat cultures
are not ill with acute streptococcal phaiyngitis but
rather are long-term carriers.
In a recent symposium cosponsored by Ross Labs
and the American Heart Association and endorsed by
NIH, the following recommendations were agreed to:
• “Throat cultures should remain the basis for
diagnosis . . .” of strep in the age group 4 to 20; a
negative culture avoids unnecessaiy prescribing of
antibiotics.
• Oral penicillin is preferred to benzathine penicillin
(except in predictably veiy poor compliance) because
of its reduced anaphylaxis risk. “Whenever practical,
therapy should be delayed until culture results are
available.”
‘Abstracts are from the Department of Pediatrics Newsletter,
UMDNJ-New Jersey Medical Society, Vol. 9, No. 7, 1984. Dr.
Rapkin is Editor and Medical Director of Children's Hospital
of New Jersey, Newark. Coeditors are Dr. Behrle, Professor and
Chairman, Department of Pediatrics, UMDNJ-New Jersey
Medical School, and Dr. Sun, Director of Neonatology, Chil-
dren's Hospital of New Jersey, Newark. Correspondence may
be addressed to Dr. Rapkin, Children’s Hospital of New Jersey.
15 South 9th Street, Newark, NJ 07107.
>L. 81— NUMBER 11— NOVEMBER 1984
973
• Followup cultures are not indicated since they
usually only identify long-term carriers for whom re-
peated courses of antibiotics are not indicated.
• Cultures of asymptomatic contacts are not in-
dicated.
The American Heart Association will likely adopt
these principles very soon. They are eminently reason-
able and ought to form the basis for our current man-
agement of phaiyngitis.
Lo CW, et al.: Chronic protracted diarrhea of infancy:
A nutritional disease. Pediatrics 72:786, 1983.
Intractable diarrhea of infancy has been known for
decades. It is believed to be a vicious cycle of diarrhea,
malabsorption, malnutrition, and failure to thrive.
Although the mechanisms that contribute may vaiy,
the syndrome which results has mucosal atrophy and
malabsorption and the eponyrn “slick-gut syndrome”
has been used. Malnutrition is not only one of the
major contributors to intractability (inability to re-
generate gut mucosa) but also is the major conse-
quence of the syndrome. After known causes have been
ruled out by a thorough workup (and, almost always,
this includes a small bowel biopsy), the diagnosis
usually is obvious. Treatment often is protracted and
requires enteral or parenteral alimentation. Prevention
often is possible by recognizing that a nutritional
emergency exists in marginally nourished infants with
gastroenteritis and acting appropriately: avoidance of
iatrogenic starvation, i.e. clear fluids and diluted for-
mulas.
The latter is the most important aspect for the pri-
mary care physician to recognize. The small marginally
nourished infant with gastroenteritis must be fed. If
fluid losses are excessive, the infant can receive paren-
teral fluid replacement simultaneous with feeding.
Mok JYQ, et al.: Symptoms, atophy, and bronchial
reactivity after lower respiratory infection in infancy.
Outcome for acute bronchitis, bronchiolitis, and
pneumonia in infancy. Arch Dis Child 59:299, 306,
1984.
Two hundred children admitted to the hospital with
lower respiratory infection were followed for seven
years as well as matched controls. Index cases had an
increased incidence of cough, wheezing, asthma and
bronchial reactivity compared to controls. When the
cases were segregated by disease category (bronchitis,
bronchiolitis, pneumonia), there were no differences
between but each category differed from controls in the
above symptoms and signs. When the cases were segre-
gated by atopic background or not, there were again
no difference between, but each category differed from
controls, in the same ways.
The authors also noted that bronchial hyper-reac-
tivity was equally distributed among atopic and
nonatopic subgroups and speculate that “infection of
the respiratory tract during a vulnerable period of lung
growth in infancy causes direct injury or induces
changes that lead to an increase in respiratory symp-
toms and impairment of lung function during child-
hood.”
The confusion of which causes what, and what
predisposes to which is not clarified by this fine group
of studies. The data are worth careful considerate
and add to our storehouses of knowledge, even thouj
they do not solve the puzzle.
Rumack BH: Acetaminophen overdose in young ch
dren. Am J Dis Child 138:428, 1984.
This article represents another collaborative stu
by the Rocky Mountain Poison Control Center foci
ing on the side effects of overdosage by acetaminoph
elixirs and alcohol-containing drugs for a specific a:
group of six years and younger. This research cc
eluded that when an acetaminophen plus alcohol dr;
is taken in toxic doses, hepatoprotection occurs,
SGPT, SGOT, and bilirubin have a mild increase. T:
laboratory results are in distinct contrast to to::
doses of acetaminophen taken alone or with a co-
bination of other drugs such as propoxyphene, c
deine, antihistamines, or anticholinergics. The clinfl
level of safety is greater for acetaminophen overdo
in a young child compared to an adolescent or adv;
This indicates some degree of hepatoprotection in tjj
young child to the toxic metabolites of acetaminoph
A tenfold increase in dosage is necessary beforu
potential threat exists in the child. However, the pi I
sieian still must determine the acetaminophen lev!>
in the blood in any overdosage. If the levels are abr
the established nomogram levels at 4 or more hou
after ingestion, or by history a patient has inges 1
150 mg/kg and levels cannot be determined within i
hours, the specific antidote of oral acetycyste jj
should be started in order to prevent irreversi1
hepatic damage.
Fever control should be reviewed with parents, p -
ing specific attention to type of antipyretic and s
dosage. Because acetaminophen has noncumulate
kinetics and levels are not increased in dehydrat jj
states, it is the safest antipyretic for the young chi.
Hobbs, CJ: Skull fracture and the diagnosis of abu .
Arch Dis Child 59:246, 1984.
Eighty-nine children under two years of age up
skull fracture were studied retrospectively. The fu-
ture characteristics more often found in abused cli-
dren were: multiple or complex fractures; depresd.
wide and growing fractures; involvement of more tip
one cranial bone; nonparietal fracture; associated -
tracranial injury including subdural hematoma The
were no fractures over 5 mm wide in nonabused cl
dren and most accidents usually resulted in sirf
narrow, linear fractures, most commonly of the pari1 il
bone. The author suggests that in young child) ji;
where a minor fall is alleged, the character of a s jll
fracture may help in recognizing abuse.
The author mentions that the diagnosis of ab e
was assisted by the presence of multiple injus
characteristic of abuse in 27 of 29 cases. This is w
important to recognize and in the author’s wo s,
“Many of the children represent the severe end of £
spectrum of skull fracture in abuse. It is possible ifj
‘more gently battered babies’ might be indisr
guishable from those having minor falls.” Neverthelis.
the fracture characteristics described in this a rle
should be useful adjuncts in the ongoing probler
diagnosing child abuse.
974
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JEF f
NJ Members . . .
has never been a better time to improve your Keogh and Corporate Retirement Plans
i Care Consulting, Inc. (HCC), primary
je of THE HEALTH CARE GROUP, and
edical Society of New Jersey introduce
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ractice needs
pntaining more than 30 comprehen-
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implying with TEFRA as you must in 1984
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id providing innovative Ongoing Plan
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■?gy OF NEW JERSEY
EXECUTIVE OFFICER r, , I
CES ° Two PRIWcfcq an
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L. 81— NUMBER 11— NOVEMBER 1984
975
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)OCTORS’
rOTEBOOK
rustees’ Minutes:
eptember 16, 1984
A regular meeting of the Board of
rnstees was held on September 16,
184, at the Executive Offices in
iwrenceville. Detailed minutes are
i file with the secretary of your
unty society. A summary of sig-
jficant actions follows:
;w Jersey Orthopaedic Society
rant . . . Received a check for
,000, the second of three con-
ibutions from the New Jersey Or-
opaedic Society.
jport of the President . . .
re Institute of New Jersey . . .
)ted that MSNJ was honored by
e Eye Institute of New Jersey for
onsoring the yearly Eye Health
reening Program.
;port of the Executive Director . . .
) MSNJ 1984 Membership . . .
pted that paid membership was
150 as of August 31, 1984.
) Continuing Medical Education
• Noted that a mailing was sent to
0 members who failed to main-
in their continuing medical edu-
tion status.
) Review of MSNJ Financial
Statements . . . Reviewed financial
statements for the periods ending
June 30 and July 31, 1984.
(4) Auto Leasing Proposal . . . Ap-
proved the following recommen-
dation:
That staff proceed to negotiate an auto
leasing arrangement in accordance with
the details outlined in the August 10,
1984, memorandum of the Executive Di-
rector.
(5) Status Report on Legal
Matters . . .
(a) Subordinated Loan Certificates
—Internal Revenue Service . . .
Noted that a report of the hearing
examiner is expected in November
and a decision of the U.S. Tax Court
would come shortly thereafter.
(b) State Board of Medical Exam-
iners versus Greco . . . Noted the
Appellate Division upheld the SBME
decision and MSNJ has filed a peti-
tion for certification to the New Jer-
sey Supreme Court.
(6) Regulatory Proposals . . .
(a) State Board of Nursing— Nurse
Anesthetists . . . Accepted the fol-
lowing proposal on the basic qualifi-
cations for a nurse anesthetist: have
a current license to practice as a
registered professional nurse: have
graduated from a program in nurse
anesthesia accredited by the na-
tionally recognized accrediting body
approved by the Board of Nursing;
have passed the certifying examin-
ation administered by that author-
ity: and have maintained the re-
quired certification criteria
(b) State Board of Medical Exam-
iners— Termination of Pregnancy
. . . Accepted the following proposal
specifying the circumstances under
which a medical practitioner could
perform certain types of termination
of pregnancy at more advanced
stages: as long as the procedures are
done in licensed health care facili-
ties, and that facilities performing
terminations of pregnancy during
the second trimester must have a
medical director and a credentials
committee which evaluates and de-
termines the ability of the operating
physician to conduct the various
types of termination procedures to
be consistent with the health, safety,
and welfare of the public.
(c) State Board of Medical Exam-
iners—Delegation of Physical Mo-
dalities to Unlicensed Physician
Aides . . . Noted MSNJ’s generally
supportive position on unlicensed
physician aides, with the exception
of the inclusion of podiatrists and
chiropractors directing aides or
physical therapists. Noted that the
rule was accepted by SBME and
MSNJ’s letter on the issue was re-
ferred to the Credentials Committee.
(7) Medicare Fee Freeze . . .
Directed that a fact sheet be de-
veloped and circulated to the mem-
bership setting forth the pros and
eons of the Medicare amendments
and an explanation of “partici-
pating” and “nonparticipating”
physicians. In addition, referred to
the Council on Public Relations the
motion to take steps to explain this
situation to the media with the
possibility of a full-page ad in all
major New Jersey newspapers. Also,
agreed that consideration should be
given to providing posters and book-
lets for distribution in physicians’
offices.
Council on Legislation . . .
(1) Assignment of Benefits to
Physicians . . . Approved the follow-
ing recommendation:
That MSNJ seek amendment to the
current law, making it a requirement
that when assignment of benefits is
made by a patient to a physician, the
insurance company must pay the phy-
sician. Also, if the insurance company
inadvertently pays the patient, the in-
surance company must pay the phy-
sician and then retrieve the money from
the patient. (It is suggested that the New
York State law be used as a guide.)
(2) Current State Legislation . . .
Approved all the positions rec-
ommended by the Council on Legis-
lation, with the exception of
A-1881, 1882, 1883, 1884, and
1885 (organ transplants) which
were changed from “approved” to
“no action.” (The list will be publish-
ed in the next issue.)
(3) Fall Conferences . , . Approved
the following recommendation:
That the Fall Conference be devoted to
legislative and lobbying activities and be
conducted under the auspices of the
Council on Legislation.
Committee on Annual Meeting . . .
(1) 1985 Daily Schedule . . . Ap
proved the following recommen-
dation:
That the Board of Trustees approve the
proposed daily schedule for the 1985 An-
nual Meeting.
:>L. 81— NUMBER 11— NOVEMBER 1984
977
(2) Sessions of the House of Del-
egates . . . Approved the following
recommendation:
That the Committee on Revision of
Constitution and Bylaws be instructed to
prepare an amendment to the Bylaws
which would transfer the election from
the second session of the House of Del-
egates to the third session of the House
of Delegates.
Committee on Retirement Plan for
Physicians . . . Noted that the Com-
mittee approved the program offered
by the Health Care Group and
agreed that it should be an endorsed
program of MSNJ.
State Board of Medical Examiners
. . . Approved the following rec-
ommendation:
That should the Medical Inter-In-
surance Exchange of New Jersey decide
to appeal the case of Ignacio Cruz, M.D.,
that MSNJ join the case in an amicus
position.
Old Business . . .
( 1 ) Health Care Facilities Planning
Act— Certificate of Need . . . Agreed
to notify the Commissioner of
Health that MSNJ will support legis-
lation (S-1840) which calls for the
total exemption of the private prac-
tice of medicine from the certificate
of need law.
(2) Special Hearing on UMDNJ’s
Medical Education Programs . . .
Instructed the President or his de-
signee to attend a panel hearing that
would be reviewing UMDNJ's medi-
cal education programs.
Correspondence . . .
(1) From John C. Berry, Directoi
Department of Health and Huma
Services, Bureau of Program Ope:
ations . . . Noted the response t
advertising on behalf of HMOs (Re:
olution #26):
"Under Section 1876 of the Soci;
Security Act, HMOs can contra*
with the federal government to ei
roll Medicare beneficiaries an
provide covered services to then1;
Following an HMO’s federal qualif
cation and subsequent contra*
with the Health Care Financing A*
ministration, and at the request *
the HMO itself, notices are maile
out to each beneficiary residing i
the service enrollment area of tn
HMO.
“It is not our intent to promoi
one health care delivery system ov*
another. The purpose of the notic
is simply to inform beneficiaries <
the existence of an alternative to tf
traditional fee-for-service syster :
Because the federal government he
an obligation to notify beneficiarie
of federal programs of their righi
under these programs, we beli^
that such mailings are appropriat
The notice was developed to a
quaint beneficiaries with an altem;;
tive system with which most are ui :
familiar.
“The language of the notice, whic
has been approved by the America
Medical Association, was designej;
to be purely informational in natunj
not to encourage the use of HMCI
over the fee-for-service system. Th!
notice specifically states that enrol; I
ment in the HMO is optional an:
that Medicare beneficiaries who s|l
choose may continue to receiy j
health care from their present pfy
sicians and other providers.”
(2) From J. Richard Goldstein;
M.D., State Commissioner o;
Health . . . Noted response to Resc; I
lution #12 on water pollution:
“Please be assured that we shar
the concern of the Medical Society c
New Jersey as expressed by Resole
tion #12.
“We have been advised that Nei!
York City is in the midst of a cor
truction program to complete th
North River and Red Hook treatmer
plants by the end of 1985. The Nort
River plant is expected to be on lin
by the time the convention center i
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jer-
sey. This special issue illuminates the beginnings of our
health care system and the growth of medical care: essays
highlight those talented individuals who devoted themselves
to this system, and commentaries present the development
of specialized care in associated fields of medicine. Plus a
special photography section highlighting three statewide
exhibits.
Copies of this issue are available by sending $5.00
(check or money order) to MSNJ, Two Princess Road, Law-
renceville, NJ 08648. All MSNJ members will receive one copy
of this issue.
Name
978
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
■ompleted and it is anticipated that
he sewage waste from there will be
reated by that plant.
“The issue of the raw sewage dis-
harge by New York City into the
Hudson and East Rivers should be
iddressed in large part by the eom-
)letion of the two treatment plants.
Vhile the elimination of much of the
aw sewage discharge should result
n some improvement in water
luality, there are a number of other
actors, such as sludge dumping, in-
lustrial discharges, run off, and
ombined sewer systems which
rypass treatment during heavy
ains, which negatively impact on
vater quality in the northern New
Jersey-New York area and may affect
ecreational bathing beaches in
Monmouth and Ocean Counties,
rhese issues are being addressed by
tew Jersey-DEP, the U.S. En-
/ironmental Protection Agency, the
tew York State Department of En-
/ironmental Conservation, the New
fork City Department of En-
/ironmental Protection, the Inter-
state Sanitation Commission, and
others.
“I have taken the liberty of for-
varding a copy of Resolution #12 to
he Interstate Sanitation Com-
nission for their review.
“I would like to commend the
Medical Society of New Jersey for
aking the time to express your con-
:ems on this issue.”
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
Resident
As this column goes to press, I am
rwaiting the recommendations of a
ranel of five distinguished
educators and scientists who were
lamed to review our South Jersey
nedical education programs. In ac-
cord with a resolution of the New
Jersey Board of Higher Education,
he panel was asked to focus on the
ong-term suitability of the Univer-
sity’s multiple existing programs for
meeting the State’s needs with phy-
sicians educated according to the
lighest standards.
Specific questions being ad-
dressed include: Should UMDNJ os-
eopathic students receive two years
bf basic science instruction at
JMDNJ-Rutgers Medical School in
Piscataway and then transfer south
or clinical instruction under School
bf Osteopathic Medicine faculty at
SOM’s hospital affiliate? Should a
basic science capacity be added to
SOM so that its entire four-year pro-
gram is offered in one location?
In late September, the group vis-
ited the Piscataway campus, Tren-
ton, and the Camden area to hear
firsthand from UMDNJ and Depart-
ment of Higher Education leaders,
as well as other interested parties,
on the South Jersey medical educa-
tion programs.
The panel was to examine the
scope, quality, and effectiveness of
the medical education which
UMDNJ provides in southern New
Jersey through UMDNJ-Rutgers
Medical School, Camden, and
UMDNJ-School of Osteopathic Medi-
cine, Camden and Stratford. New
Jersey’s need for physicians, the
statewide distribution of health care
personnel and facilities, and the
state’s fiscal capability were to be
considered.
The consulting group was ex-
pected to scrutinize the quality of
both existing and proposed cur-
ricula, faculty and interschool fac-
ulty relationships, educational facili-
ties, student performance, and hos-
pital and professional relationships
among both M.D. and D.O. institu-
tions, physicians, and faculty.
We are fortunate to have on the
panel for this crucial study Dr. Ivan
L. Bennett, Jr., executive vice-presi-
dent for health affairs of New York
University: Dr. Leighton Cluff, ex-
ecutive vice-president of The Robert
Wood Johnson Foundation: Dr.
Myron Magen, dean of Michigan
State University; Dr. Max Michael,
Jr., assistant vice-president for
health affairs of the University of
Florida: and Dr. Steven Beering,
M. D., president of Purdue Univer-
sity.
The otolaryngology-head and neck
surgery section of UMDNJ-New Jer-
sey Medical School, Newark, has de-
veloped a light, flexible silicone rub-
ber prosthesis for the patient whose
larynx has been removed and has
not succeeded in recovering the
ability to speak by using the "burp
talk" technique.
With the help of this new
prosthetic device, which has been
approved by the Food and Drug Ad-
ministration, most patients easily
can learn to speak by diverting air
up through the throat and forming
word sounds by working the throat
muscles. Good results have been ob-
tained in about 40 patients with the
device, which costs $25 and lasts
three to six months.
Services provided by the “Post-
Laryngectomy Voice Rehabilitation
Program” at UMDNJ’s University
Hospital include surgery to prepare
the patient for insertion of the
prosthesis, instructions in its use,
and followup care.
The “New Jersey Larynx,” also de-
veloped at UMDNJ-New Jersey Medi-
cal School, used the patient’s skin to
form a substitute larynx, but that
must be done at the time the larynx
is excised surgically.
The purchase of a computerized
gamma camera, able to take pictures
at the rate of one million counts per
second, has been made possible by
a $179,000 gift to UMDNJ-Rutgers
Medical School by the Fannie E. Rip-
pel Foundation, Madison. The Scin-
ticor will make possible a procedure
called “first pass isotope technique"
that is safe, painless, and as ac-
curate as possible in evaluating the
condition of the patient’s heart. The
data will enable physicians to
prescribe the most effective treat-
ment for their patients and help
them to decide which ones would
benefit from surgery. A portable unit
will be used on cardiac patients at
Middlesex General-University Hospi-
tal, New Brunswick, before, during,
and after heart surgery. It can be
used at bedside in intensive care or
the operating room. The Scinticor
also will be used for research at the
medical school.
MSNJ Auxiliary
Grace Ge liman
President
The chairman of the Impaired
Spouses of Physicians Committee,
Josephine Pesaresi, attended the
Sixth AMA Conference on the Im-
paired Physician in Secaucus. Also,
representing the Auxiliary was
Bergen County Medical Society Aux-
iliary President, Barbara Goldstein.
The Fall Leadership Workshop in
Lawrenceville was well attended and
enthusiastically received. John J.
Moore, Ph.D., Professor at Loyola
University, Chicago, presented a
dynamic program on “Avenues
Leading to Personal Success,” and
“Ingredients for Self-Assurance.”
Five county presidents-elect —
representing Bergen, Mercer, Salem.
Sussex, and Union Counties—
/OL. 81— NUMBER 11— NOVEMBER 1984
979
attended the AMA Auxiliary Leader-
ship Confluence in October in Chi-
cago.
Evelyn Basralian, convention
chairman, and the Committee, met
at Americana Host Farm Resort in
Lancaster. The members really have
a treat in store during May 2-5,
1985. A fun program, together with
the regular business, is in the plan-
ning stage.
It is time to think “holidays.”
AMA-ERF chairman, Marilyn
Pashuck has great boutique items
and at a saving. Invite her to your
county meetings and just see. Con-
sult your county auxiliary AMA-ERF
chairman to assist you in selecting
holiday cards for your office from an
outstanding selection.
Happy Thanksgiving!
AMNJ Report
Robert S. Rigolosi, M.D.
President
In late August, the Academy of
Medicine mailed its popular Annual
Calendar for 1984-1985 to all Fel-
lows and Institutional Members
throughout New Jersey. Receipt of
this publication always is a signal
that the academic year is about to
begin and it appears from the im-
pressive content that this will be our
most prolific year ever.
On September 12, our Education
Committee, under the chair-
manship of Dr. A1 Alessi, held their
annual joint meeting with our scien-
tific section officers. The purpose of
the meeting was to orient the new
committee members and section of-
ficers to their role in the category I
accreditation process and the mech-
anism to schedule section meetings.
Over 30 members and staff were in
attendance.
The Academy in conjunction with
the Medical Society of New Jersey
and the AHME of New Jersey held a
workshop on CME essentials on
Wednesday, September 18, 1984, at
the Executive Offices. The Work-
shop, designed for directors of medi-
cal education, coordinators of CME,
hospital medical directors, quality
assurance directors, and hospital
staff involved in CME management,
studied the following: exposure to a
broad range of needs assessment
procedures from faculty and fellow
participants: needs assessment con-
cepts and techniques which best
apply to a particular environment;
one or more accreditation site
survey scenarios and determination
of the collegial and consultative
nature of the site survey process;
and definition of what is expected in
the accreditation and site survey
process.
On Saturday, October 13, 1984,
the Academy will be sponsoring its
first major symposium of the
academic year. The program, “Hy-
perthermia for Cancer,” will be held
at the Executive Offices and the pro-
gram chairman is Dr. Arthur Winter.
The symposium will present the
most current scientific information
concerning the concomitant use of
hyperthermia in the treatment of
cancer of the body, including the
brain.
Our second major symposium will
be held on Saturday, October 20,
1984, at the Town and Campus Res-
taurant in West Orange. Dr. Donald
Louria will chair, “Potential Human
and Ecologic Disasters,” which
among other areas will examine the
health effects of exposure to leakage
from chemical toxic waste disposal
sites and all the available studies
that have been completed will be re-
viewed and the requirements for ad-
ditional study will be analyzed. High
and low level radiation exposure
consequences also will be discussed.
The speaker for the Academy’s
first First Wednesday program of the
year was Dr. David Rogers, president
of the Robert Wood Johnson Foun-
dation. Dr. Rogers addressed the
topic, “Cutting Medical Care Costs,”
with comments from his recent
JAMA article.
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ANESTHESIOLOGY— Howard Ang, M.D.,
7 29 Hegeman Ave., #3-A Brooklyn, NY
11212. Far Eastern University 1976.
Group or partnership. Available Janu-
ary 1985.
FAMILY MEDICINE— Maiy F. Cam-
pagnolo, M.D., 10 Overlook Rd„ Apt. 5-
E, Summit, NJ 07901. George Wash-
ington University 1982. Board eligible.
Group or partnership. Available July
1985.
Caiy A. Davidson, M.D., 100B Findeme' it
Ave., Bridgewater, NJ 08807. SUNY-Up
state 1982. Board eligible. Rural or
suburban practice, family practice,
solo, group. Available July 1985.
GASTROENTEROLOGY— Kenneth
Russell Feuer, M.D., 3120 Parkway,
Cheverly, MD 20785. Baylor 1980. Also
internal medicine. Board certified (IM),
Available July 1985.
Henry J. Katz, M.D., 20 Waterside Plaza
New York, NY 10010. Albany Medical
College 1980. Board certified (IM).
Group or partnership. Available.
Eliot H. Zimbalist, M.D., 430 East 67
St., Apt. 12F. New York, NY 10021. Mt.il
Sinai 1980. Also internal medicine. 1
Board certified (IM). Group, partner- \
ship, multispeeialty. Available July1
1985.
GENERAL MEDICINE — Parviz Babalavi, (
M.D., 6265 Austin St., Rego Park, NY
1 1374. Tehran (Iran). Hospital or office
setting, ENT background. Available.
INTERNAL MEDICINE— David M. Breid- ,
bart, M.D., 50 Hillpark Ave., Apt. 1-R
Great Neck, NY 11021. SUNY- Down-
state 1979. Also pulmonary medicine.
Board certified (IM); board eligible
(PM). Pulmonary, pulmonaiy/intemal
medicine, multispecialty group. Avail-
able July 1985.
Kenneth Russell Feuer, M.D., 3120
Parkway, Cheverly, MD 20785. Baylor
1980. Also, gastroenterology. Board
certified. Available July 1985.
Cory Krueger, M.D., 2301 Woodward St.
Apt. C-12, Philadelphia PA 19115.
Rutgers 1982. Board eligible. Group or ,
partnership. Available July 1985.
Gianfranco Umberto Meduri, M.D., 430
East 67 St., Apt. 9C, New York, NY
10021. Padua (Italy) 1977. Also,
pulmonary. Board certified (IM).
Group, academic, industrial. Available
August 1985.
Virod K. Shah, M.D., 345 Watkins Lane,
Battle Creek MI 49017. M.P. Shah
(India) 1975. Board eligible. Any type
practice. Available.
Robert L. Werner. D.O., 148 Reservoir
Rd., Parsippany, NJ 07054. UMDNJ-
NJSOM 1981. Board eligible. Solo or
partnership. Available July 1985.
OBSTETRICS/GYNECOLOGY— Nissim
Contente, M.D., 7300 Cedar Post Rd.,
Apt. 10E, Liverpool, NY. Guadalajara
(Mexico) 1979. Board eligible. Group or
partnership. Available July 1985.
Amnon Fein, M.D., 223 East Ave., Apt.
6B, Syracuse, NY 13224. Guadalajara
(Mexico) 1980. Group or partnership.
Available July 1985.
OCCUPATIONAL MEDICINE— Errol j
Emmet Vernon, M.D., 2018 Pickerton
Dr„ Deer Park TX 77536. University of
the West Indies (Jamaica) 1978. Board
eligible. Group. Available.
980
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
PTHALMOLOGY— George R. Coar,
1 M.D., 3245 Beechwood Blvd., Apt. C-l 1,
Pittsburgh, PA. Jefferson 1981. Board
eligible. Group, partnership, solo. Avail-
able July 1985.
Peter J. Famiglietti, M.D., Box 76, R.D.
#5, Danville, PA 17821. University of
Connecticut 1981. Board eligible.
Group or partnership. Available July
1985.
, Barry N. Shaklan, M.D., 6207 Blaek-
' berry Lane, Dallas, TX 75248. Seton
Hall 1961. Board certified. Available.
'aTHOLOGY— Steven P. Katz, M.D.,
9634 S. Karlov Ave., Oak Lawn, IL
! 60453. Nebraska 1972. Board certified
' (PA and CLIN). Hospital or group. Avail-
1 able on one month's notice.
’EDIATRICS— Charles H. Geneslaw,
! M.D., 8372 Loveridge Ct„ Richmond,
VA 23229. UMDNJ 1982. Partnership.
Available July 1985.
Nellie Novak, M.D., 1015 West Cherry
Hill Apts. Cherry Hill, NJ 08002.
Sverdlovsk (USSR) 1974. Board
eligible. Group, partnership, HMO.
Available July 1985.
’ULMONARY MEDICINE— David M.
Breidbart, M.D., 50 Hillpark Ave., Apt.
1-R Great Neck, NY 11021. SUNY-
Downstate. Also, internal medicine.
Board eligible (PM); board certified
(IM). Pulmonary, pulmonary/intemal
medicine, multispecialty group. Avail-
able July 1985.
Gianfranco Umberto Meduri, M.D., 430
East 67 St„ Apt. 9C, New York, NY
10021. Padua (Italy) 1977. Also,
internal medicine. Board certified (IM).
Group, academic, industrial. Available
August 1985.
SURGERY — Victor P. Bruno, M.D., 702
Fordham Rd„ Bala Cynwyd, PA 19004.
Georgetown 1978. Board eligible.
Group or partnership. Available May
1986.
Daniel M. Goldman, M.D., 3450 Wayne
Ave., Apt. 19-S, Bronx, NY 10467. Also,
vascular surgery. Board eligible. Part-
nership or single specialty group.
Available July 1985.
David A. Guthrie, M.D., 3130 Heath-
stead PL, Charlotte, NC 28210. West
Virginia 1978. Also, vascular surgery.
Board eligible. Group or partnership.
Available July 1985.
SURGERY, VASCULAR— Daniel M.
Goldman, M.D., 3450 Wayne Ave., Apt.
19-S, Bronx, NY 10467. Also, general
surgery. Board eligible. Partnership or
single specialty group. Available July
1985.
David A. Guthrie, M.D., 3130 Heath-
stead Pl„ Charlotte, NC 28210. West
Virginia 1978. Also, general surgery.
Board eligible. Group or partnership.
Available July 1985.
UROLOGY— Richard S.D. Tushman,
M.D., 519 Vantage PL, Richmond, VA
23236. Cornell 1980. Board eligible.
Available July 1985.
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
LIPO-NICIN
Nicotinic Acid Therapy
For patient’s
comfort/convenience
in choice of
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL(B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets daily.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg. #||
Each blue tablet contains: ''Ifp
Nicotinic Acid 100 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
(br§EJ2> the BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057 IPDR
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
-Bi W Mm
&/ W -:i' '-M zz i
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feV-’v
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care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
you practice.
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program,
for more information please call - '
(201) 456-3200.
The card that you can count on...
Rf]) Blue Shield
JJ of New Jersey
984-1985 Committees & Councils
\NDING COMMITTEES
tnmittee on Annual Meeting
iff Liaison, Eileen Pfeiffer)
nk R Romano, Sr., M.D.,
Chairman (1985) Dunellen
imas J. Connolly, Jr„ M.D. (1987) Jersey City
rren E. Crane, M.D. (1986) Trenton
want G. Keswani, M.D. (1987) Livingston
n F. Marshall, M.D. (1986) Trenton
1 A. Restivo, Sr„ M.D. (1985) Wayne
John Holdcraft, Auxiliary
Member (1985) Woodbury
lur Bernstein, M.D., Secretary.
Ex-ojficio Member South Orange
S. Cherashore, M.D., Consultant Nutley
rving Dunn, M.D., Consultant Mantoloking
Grew G. Hudaeek, M.D., Consultant Morristown
i irles S. Krueger, M.D., Consultant Mount Holly
I eph E. Salvatore, M.D., Consultant Tenafly
I
entitle Program (Sections)
■iff Liaison, Eileen Pfeiffer)
l;rgy
*ela S. Salanito, M.D., Chairman Upper Montclair
d Bigelsen, M.D., Secretary Dover
sthesiology
(er A. Moore, M.D., Chairman Moorestown
ia Hupert, M.D., Secretary Livingston
diovascular Diseases
|lul N. Timmapuri, M.D., Chairman Ridgefield Park
ly K Thamman, M.D., Secretary Lodi
;st Diseases
in Berlin, M.D., Chairman Jersey City
oical Pathology
ig H. Hyun, M.D., Chairman Plainfield
bert R Riekert, M.D., Secretary Livingston
rmatology
H. Gouterman, M.D., Chairman Roseland
ergency Medicine
ert H. Helm, M.D., Chairman West Collingswood
dolf E. Schwaeble, M.D., Secretary Mendham
nily Practice
ristopher Babigian, M.D.,
Chairman Par am us
stroenterology, Colon and Rectal Surgery
H. Fischer, M.D., Chairman Fair Lawn
in C. McConnell, M.D., Secretary Fair Lawn
urosurgery and Neurology
an L. Gardner, M.D., Chairman Summit
urice M. Davidson, M.D., Secretary Somers Point
ste tries and Gynecology
;eph A. Varallo, M.D., Chairman Atlantic City
"nard A. Pekala M.D., Secretary Cherry Hill
geology
xander Z. Haas, M.D., Chairman New Brunswick
lliam M. Schulman, M.D., Secretary Lakewood
hthalmology
al M. Tishler, M.D., Chairman Willingboro
vid I. Gerstein, M.D., Secretary Irvington
thopaedic Surgery
njamin I. Smolenski, M.D., Chairman Mt. Laurel
bert J. Weierman, M.D., Secretary South Orange
^laryngology. Head and Neck Surgery
'mund L. Sattenspiel, M.D., Chairman Freehold
phen F. Mattel, M.D., Secretary Clifton
iia tries
ward Arkans, M.D., Chairman Moorestown
ysical Medicine and Rehabilitation
ampa V. Bid, M.D., Chairman West Orange
nn J. Kraus, M.D., Secretary Morristown
istic and Reconstructive Surgery
gene C. Carroecia, M.D., Chairman Ventnor City
pchiatry
nneth J. Rubin, M.D., Chairman Long Branch
Radiology
Charles A. Whelan, M.D., Chairman Montclair
David V. Habif, Jr., M.D., Secretary Teaneck
Rheumatology
Kenneth H. Maurer, M.D., Chairman Cherry Hill
David M. Sagransky, M.D., Secretary Linwood
Surgery
Edward W. Vemer, M.D., Chairman Newark
Ralph S. Greco, M.D., Secretary New Brunswick
Advisory Committee to the Auxiliary
(Staff Liaison, Shirley Walsh)
Frank R Romano, Sr., M.D., Chairman (1985) . Dunellen
George T. Hare, M.D.,
Vice-Chairman (1986) Haddonfield
Ralph J. Fioretti, M.D.,
President-Elect (1986) Rochelle Park
Werner J. Hollendonner, M.D. (1985) Hamilton Square
Joseph N. Micale, M.D. (1987) North Bergen
J. James Pegues, M.D. (1987) Mount Holly
Mrs. Ralph B. Wayman, Jr., Auxiliary
Member { 1985) Yardley, PA
Committee on Credentials
(Staff Liaison, Arthur White)
Arthur Bernstein, Chairman. Secretary,
Ex-ojficio Member South Orange
Thomas E. Mattingly, Jr., M.D.,
Vice-Chairman (1985) Mount Holly
William A. Allgair, M.D. (1985) South River
Edward M. Coe, M.D. (1986) Cranford
James N. Judson, M.D. (1987) Cape May Court House
Roger C. Laauwe, M.D. (1986) Wayne
Lawrence B. Owen, M.D. (1987) Salem
Committee on Finance and Budget
(Staff Liaison, Arthur White)
Harry M. Carnes, M.D., Chairman (1987) Audubon
Palma E. Formica, M.D.,
Vice-Chairman (1985) Old Bridge
Douglas M. Costabile, M.D. (1987) Murray Hill
Matis A. Fermaglieh, M.D. (1987) Teaneck
Edward A. Sehauer, M.D. First
Vice-President (1987) Farmingdale
B. Ralph Wayman, Jr., M.D. (1986) Yardley, PA
Mrs. Elmer Grimes, Auxiliary
Member (1985) Haddonfield
Paul J. Hirseh, M.D., Treasurer, Ex officio
Member Bridgewater
Committee on Medicaid
(Staff Liaison, Joseph C. Lucci)
Thomas S. Bellavia, M.D.,
Chairman
James Q. Atkinson, M.D
Gertrude B. Brundage, M.D
Bayard Coggeshall, M.D
Jonathan C. Gibbs, M.D
Sheldon Lang, M.D
Arganey L’Avnire Lucas, Jr., M.D
Bernard A. Pekala M.D
Carl J. Records, M.D
William Silverman, M.D
Murray Pine, D.O., Consultant
Frank Y. Watson, M.D., President
Invited Guest
Ralph J. Fioretti, M.D., President-Elect.
Invited Guest
1. Fulton Erlichman, M.D.. Invited Guest
Jack Kallop, Invited Guest
Thomas Russo, Invited Guest
S. Eugene Yuliano, M.D., Invited Guest
Joseph C. Lucci, Invited Guest
Hasbrouek Heights
Vincentown
East Orange
Morristown
Jersey City
Passaic
Morristown
Cheriy Hill
Rio Grande
Atlantic City
Newark
Glen Ridge
Rochelle Park
Trenton
Millville
Trenton
Trenton
Lawrenceville
>L. 81— NUMBER 11— NOVEMBER 1984
983
Vincent A. Maressa Executive Director,
Invited Guest Lawrenceville
Committee on Medical Defense and Insurance
(Staff Liaison, Joseph C. Lucci)
Michael J. Doyle, M.D., Chairman (1985) Neptune
E. Arthur Kratzman, M.D.,
Vice-Chairman (1987) Plainfield
Albert M. Doswald, M.D. (1987) Bridgewater
Stanley Karp, M.D. (1985) Cinnaminson
Carl A. Restivo, Jr., M.D. (1986) Jersey City
Harvey P. Yeager, M.D. (1986) West Orange
Mrs. William Allgair, Auxiliary
Member ( 1985) South River
Suresh G. Wabel, M.D., Resident
Member (1985) Edison
Christopher Seidler, Student
Representative New York, NY
Arthur Bernstein, M.D., Secretary,
Ex-officio Member South Orange
William H. Ainslie, Sr., M.D., Consultant Metuchen
Joseph V. Bocchino, M.D., Consultant Westfield
Anthony J. Bruno, M.D., Consultant Elizabeth
William J. D’Elia M.D., Consultant Spring Lake
John D. Franzoni, M.D., Consultant Trenton
Ernest C. Hillman, Jr., M.D., Consultant Glen Ridge
Paul J. Kreutz, M.D., Consultant Elizabeth
Henry Liss, M.D., Consultant Chatham
Jesse Schulman, M.D., Consultant Lakewood
Committee on Medical Education
(Staff Liaison, Martin E. Johnson)
Edwin W. Messey, M.D., Chairman (1987) Willingboro
Stephen Colameco, M.D. (1985) Camden
Brewster S. Miller, M.D. (1986) Somerville
Roberta G. Rubin, M.D. (1986) Glen Ridge
Sanford H. Vemick, M.D. (1985) Hazlet
Stephen F. Wang, M.D. (1987) Morristown
Mrs. Joseph Basralian, Auxiliary
Member (1985) Hasbrouck Heights
Jerome Yatskowitz, Student
Representative (1985) Maplewood
Alfred A. Alessi, M.D., Consultant Hackensack
Arthur Bernstein, M.D., Secretary,
Consultant South Orange
William C. Black, M.D., Consultant Hackensack
Alfonse A. Cinotti, M.D., Consultant Jersey City
Samuel F. D’Ambola M.D.,
Consultant Atlantic Highlands
Burton M. Feinsmith, M.D., Consultant Westfield
Paul J. Hirsch, M.D., Treasurer, Consultant . Bridgewater
Anthony B. Minnefor, M.D., Consultant Paterson
William F. Minogue, M.D., Consultant Summit
Dryden Morse, M.D., Consultant Browns Mills
Robert S. Rigolosi, M.D., Consultant Paramus
William S. Vaun, M.D., Consultant Long Branch
Committee on Medical Student Loan Fund
(Staff Liaison, Arthur White)
David Greifinger, M.D., Chairman (1985) Belleville
Antonio P. Battaglia, M.D. (1985) Gibbstown
Palma E. Formica, M.D. (1986) Old Bridge
Theodora J. Maio, M.D. (1987) Clifton
James P. Thompson, M.D. (1986) Upper Montclair
Mrs. Ralph B. Wayman, Jr., Auxiliary
Member (1985) Yardley, PA
Committee on Publication
(Staff Liaison, Geraldine Hutner)
Paul J. Hirsch, M.D., Treasurer, Chairman
(1985) Bridgewater
Dirck L. Brendlinger, M.D. (1987) Marlton
Frederick B. Cohen, M.D. (1986) Newark
A. Olusegun Fayemi, M.D. (1987) Teaneck
Robert M. MacMillan, M.D. (1985) Browns Mills
Leon G. Smith, M.D. (1986) Roseland
Mrs. Ralph J. Fioretti, Auxiliary
Member (1985) Rochelle Pc
Ralph J. Fioretti, M.D., President-Elect
Ex-officio Member Rochelle P;
Arthur Bernstein, M.D., Secretary,
Ex-officio Member South Orar
Arthur Krosnick, M.D., Editor,
Ex-officio Member Trent
Committee on Revision of Constitution and Byla
(Staff Liaison, Diana C. Gore)
John H. Lifland, M.D., Chairman (1986) Somerv
William Greifinger, M.D.,
Vice-Chairman (1985) Bellev
William A. Allgair, M.D. (1987) South Ri
Michael M. Heeg, M.D. (1985) Trent
Pascal A. Pironti, M.D. (1987) Sumi
Ford C. Spangler, M.D. (1986) Sal;
Mrs. James Brennan, Auxiliary
Member (1985) Cherry 1
Arthur Bernstein, M.D., Secretary,
Ex-officio Member South Orar
Hillel M. Ben-Asher, M.D., Consultant Morrista
William J. D'Elia, M.D., Consultant Spring L;
John S. Madara M.D., Consultant Sal
Heniy J. Mineur, M.D., Consultant Westfi
Charles I. Nadel, M.D., Consultant Irving
Carl A. Restivo, Jr., M.D., Consultant Jersey (
Bernard Robins, M.D., Consultant Springfi
ADMINISTRATIVE COUNCILS
Council on Legislation
(Staff Liaison, June O'Hare)
Irving P. Ratner, M.D., Chairman (1986) Willingt
Howard H. Lehr, M.D., Vice-Chairman (1987) ... Fanw
L. Willis Allen, M.D. (1987) Milh
Anthony P. Caggiano, Jr., M.D. (1986) Glen Ri
Thomas J. Connolly, Jr., (1985) Jersey <1
William J. D’Elia M.D. (1986) Spring L
Leon A. Fraser, M.D. (1985) Tren
S. Stuart Mally, M.D. (1985) Atlantic (j
Joseph N. Micale, M.D. (1986) North Bert
Bernard A. Rineberg, M.D. (1987) New Brunsvi
Arne L. Skilbred, M.D. (1987) Glen Ri
Irving Weiss, M.D. (1985) Pompton PI;
Mrs. Frank Campo, Auxiliary Member (1985) Trent)
William D. Salerno, M.D., Resident
Member (1985) Saddle Br
David M. MacPeek, M.D., Alternate Resident
Member (1985) Bensalem,ji
Thomas M. Fynan, Student
Representative (1985) Someji
Joseph P. Cillo, M.D., Consultant Cran 1
Frank Gingerelli, M.D., Consultant Hackensl
R Gregory Sachs, M.D., Consultant Sumi
j:
Council on Medical Services
(Staff Liaison, Joseph C. Lucci)
Joseph W. Fleisher, M.D.,
Chairman (1985) Scotch Pin
Richard H. Sharrett, M.D.,
Vice-Chairman (1986) Plain I
Joel S. Cherashore, M.D. (1985) Nijl
Stuart Hirsch, M.D. (1986) Bridgew!
John S. Madara M.D. (1986) Sal
John J. Pastore, M.D. (1987) Vineljj
Lindsay L. Pratt, M.D. (1986) Carr I
Robert S. Rigolosi, M.D. (1985) Paral
Herman M. Robinson, M.D. (1987) Living; «
David A. Willard, M.D. (1985) Princp
Edwin S. Wilson, M.D. (1987) Mount fl
Frank A Wolf, M.D. (1987) Phillips! r.
Mrs. Frank R Romano, Sr., Auxiliary
Member ( 1985) Plain!
Ralph J. Fioretti, M.D., President-Elect
Ex-officio Member Rochelle If;
984
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JER9
[atthew J. Speesler, M.D., Resident
Member (1985) Somerset
[elinda S. Lantz, Student
Representative (1985) Piscataway
ictor H. Boogdanian, M.D., Consultant . New Brunswick
arl T. Franzoni, M.D., Consultant Trenton
arl A. Restivo, Jr., M.D., Consultant Jersey City
jeffrey M. Solomon, M.D., Consultant Vineland
obert H. Stackpole, M.D., Consultant Roselle
ouncil on Mental Health
staff Liaison, Joseph C. Lucei)
reorge L. Triebenbaeher, M.D.,
j Chairman (1985) Beach Haven
j/illiam H. Bristow, Jr., M.D.,
Vice-Chairman (1986) Ridgewood
hurchill L. Blakey, M.D. (1987) Wenonah
arrell R Crouse, M.D. (1985) Woodstown
Ivin Friedland, M.D. (1986) Livingston
lorton Friedman, M.D. (1985) Millbum
.J. George, M.D. (1985) Vineland
homas R Houseknecht, M.D. (1986) Moorestown
oseph J. Kline, M.D. (1987) Trenton
i/illiam R Nadel, M.D. (1987) Plainfield
homas Robbins, M.D. (1987) Hightstown
llerald H. Rozan, M.D. (1986) Wayne
Irs. Alexander D. Kovacs, Auxiliary
Member (1985) Scotch Plains
)avid Nover, Student Representative (1985) Somerset
Jexander D. Kovacs, M.D., Immediate Past-
President Ex-ojficio Member Scotch Plains
(any H. Brunt, Jr., M.D., Consultant Wall
jnold M. Kallen, M.D., Consultant Piscataway
lartin H. Weinberg, M.D., Consultant West Trenton
Council on Public Health
Staff Liaison, Joseph C. Lucci)
Charles J. Moloney, M.D.,
Chairman (1987) Moorestown
tichard C. Reynolds, M.D.,
Vice-Chairman (1986) Piscataway
)avid J. Blackman, M.D. (1986) Wayne
Edward M. Coe, M.D. (1986) Cranford
'homas E. Desmond, M.D. (1985) Edison
dbert Ehrlich, M.D. (1985) Fort Lee
lenry A. Katz, M.D. (1985) Mountain Lakes
llenn P. Lambert M.D. (1987) Flemington
Villiam Pawluk, M.D. (1986) Medford
Jarasimhaloo Venugopal, M.D. (1987) Vineland
foseph P. Zawadsky, M.D. (1985) New Brunswick
/Irs. Guillermo Garcia Auxiliary
Member (1985) Bayonne
’aul Feldan, (1985) Student
Representative New Brunswick
'aith E. Nathan, Alternate Student
Representative Moorestown
idward A. Schauer, M.D., First Vice-President
Ex-ojficio Member Farmingdale
tonald Altman, M.D., Consultant Trenton
Council On Public Relations
Staff Liaison, Martin E. Johnson)
x)uis G. Bosco, M.D., Chairman (1987) Clifton
ioseph W. Bitsack, M.D.,
Vice-Chairman (1987) Hackensack
lohn E. Durst M.D. (1986) Freehold
Vmando F. Goraeci, M.D. (1985) Woodbuiy
dichael M. Heeg, M.D. (1986) Trenton
Robert J. Lorello, M.D. (1986) Belleville
Ion Marsicano, M.D. (1985) Iselin
Sdwin W. Messey, M.D. (1985) Willingboro
John J. Pastore, M.D. (1987) Vineland
L Gregory Sachs, M.D. (1985) Summit
lesse Schulman, M.D. (1986) Lakewood
Jeffrey M. Solomon, M.D. (1987) Vineland
drs. Paul J. Hirsch, Auxiliary
Member (1985) Bridgewater
Harry M. Carnes, M.D., Second Vice-President
Ex-ojficio Member Audubon
Frank J. Malta M.D., Consultant Toms River
Frank J. Primich, M.D., Consultant West New York
SPECIAL COMMITTEES
Committee on Biomedical Ethics
(Staff Liaison, June O’Hare)
David Eckstein, M.D., Chairman Trenton
James L. Breen, M.D Livingston
John P. Capelli, M.D Haddonfield
Joseph F. Fennelly, M.D Madison
Robert V. P. Hutter, M.D Livingston
Rudolf E. Schwaeble, M.D Mendham
Arthur Winter, M.D Livingston
Benjamin Wilfond, Student
Representative South Orange
Robert C. Cassidy, Ph.D., Consultant New Brunswick
Russell L. McIntyre, Th.D., Consultant Piscataway
Committee on Drug and Alcohol Abuse
(Staff Liaison, Martin E. Johnson)
Daniel P. Greenfield, M.D., Chairman Short Hills
William J. Annitto, M.D Summit
Jorge L. Bascara M.D Trenton
David I. Canavan, M.D Lawrenceville
Thomas R Houseknecht, M.D Moorestown
Richard M. Liss, M.D Manville
Lawrence L. Livomese, M.D Middlesex
Edwin A Turner, Jr., M.D Upper Saddle River
James S. Wales, Jr., M.D Perth Amboy
Matt Martin, Consultant Trenton
Alfred E. Palmier! M.D. Consultant Clifton
Riley Regan, Consultant Trenton
Loretta B. Ridolfi, RP„ Consultant Trenton
Richard J. Russo, M.S.P.H., Consultant Trenton
Robert Warden, D.O., Consultant Stratford
Committee on Emergency Medical Care
(Staff Liaison, Joseph C. Lucci)
Rudolf E. Schwaeble, M.D., Chairman Mendham
John A Flood, M.D., Vice-Chairman Trenton
Clifford B. Blasi, M.D Sea Girt
Ames L. Filippone, Jr„ M.D Morristown
Ronald L. Franz, M.D MorrisviUe, PA
Jack R Karel, M.D Verona
Dorson S. Mills, M.D Elmer
Robert L. Wegiyn, M.D Elizabeth
David A Halsey, Student Representative Haddonfield
Joseph Kavanaugh, Consultant Martinsville
Allen M. Koplin, M.D., Consultant Trenton
Henry R Liss, M.D., Consultant Chatham
Ellsworth Havens, Consultant Princeton
Committee on Impaired Physicians
(Staff Liaison, David I. Canavan, M.D.)
Boris G. Ivovich, M.D., Chairman Clinton
Lee Allen North Andover
Lawrence F. Barnet, M.D Paterson
Ann Beams Cranford
Warren I. Brandwine, D.O Cherry Hill
Albert M. Bromberg, M.D Springfield
Edward M. Coe, M.D Cranford
Sheila Walsh Cogan, M.D Red Bank
A Vincent DeRobbio, M.D Newark
Paul C. Fagen, M.D Montclair
Ronald I. ForsteF, M.D Union
Joseph R Fontanella M.D Point Pleasant
Joseph Giannasio, M.D Jersey City
Mark S. Gold, M.D Summit
Jerrold Goldstein, D.O Far Hills
Daniel P. Greenfield, M.D Short Hills
A Starr Ingram, M.D Westfield
Alvin Kaplan, M.D Bound Brook
Wilbur F. Kell, D.O Somerdale
Doulat Keswani, M.D Ridgewood
T)L. 81— NUMBER 11— NOVEMBER 1984
985
Andrew J.V. Klein, M.D Orange
Anthony Komninos, M.D Morristown
Thomas J. Liddy, M.D Livingston
Leonard Liebowitz, M.D Old Bridge
George W. Lutz, M.D Somerville
James Manlandro, DO.O Cape May Court House
Herbert T. McBride, M.D Toms River
Michael J. McCarthy, M.D Raritan
Arthur McLellan, M.D Summit
George J. Mellendick, M.D Perth Amboy
Rita Roslyn Newman, M.D Short Hills
Josephine Pesaresi Hackensack
George Pierson, D.O Sparta
Marcus E. Sanford, M.D Somerville
Ward M. Schultz, M.D New Providence
Frank C. Snope, M.D Piscataway
Harvey D. Strassman, M.D Camden
William C. Van Ost, M.D Englewood
Robert M. Warden, D.O Stratford
Committee on Long-Range Planning Development
(Staff Liaison, Diana C. Gore)
Bernard Robins, M.D., Chairman (1986) Springfield
Alfred A Alessi, M.D. (1987) Hackensack
William J. D’Elia, M.D. (1986) Spring Lake
Philip J. LoPresti, M.D. (1987) Haddon Heights
Thomas E. Mattingly, Jr„ M.D. (1985) Mount Holly
Frank R Romano, Sr., M.D. (1986) Dunellen
L. Arne Skilbred, M.D., (1986) Glen Ridge
Committee on Maternal and Child Care
(Staff Liaison, Joseph C. Lucci)
Peter A Beaugard, M.D. Chairman Remington
Gerard F. Hansen, M.D., Vice-Chairman Hackensack
Caterina A Gregori, M.D Livingston
John T. Harrigan, M.D New Brunswick
Thomas A Noone, M.D > Haddonfield
Thomas R C. Sisson, M.D Perth Amboy
James P. Thompson, M.D Upper Montclair
William M. Unwin, Student
Representative Highland Park
George J. Halpin, M.D., Consultant Trenton
Committee on Medical Aspects of Sports
(Staff Liaison, Joseph C. Lucci)
Christine E. Haycock, M.D., Chairman Newark
Frank L. Barham, M.D Trenton
Norman W. Garwood, M.D Crosswicks
Paul J. Hirsch, M.D., Treasurer Bridgewater
Glenn P. Lambert, M.D Flemington
Alan M. Levy, M.D Westwood
Vincent Mclnemey, M.D Paterson
Max M. Novich, M.D Perth Amboy
Benjamin I. Smolenski, M.D Mount Laurel
Peter Hyans, Student Representative Piscataway
Sarah Dougherty, Consultant Trenton
Abner West, Consultant Elizabeth
Committee on Peer Review (DRG Appeals)
(Staff Liaison, Vincent A Maressa)
William A Dwyer, Jr., M.D., Chairman Wayne
Paul I. Bookstaver, M.D Saddle Brook
Donald P. Burt, M.D Parsippany
Phillip Davison, M.D Roselle
Charles E. Dooley, Jr„ M.D Springfield
Joseph W. Fleisher, M.D Springfield
D. D. Griffith, M.D East Brunswick
Charles Harris, M.D Toms River
Alvin I. Kaplan, M.D Bound Brook
Mohammad Khan, M.D Trenton
Francis J. Lumia, M.D Browns Mills
Nelson Manowitz, M.D Springfield
A an W. Robbins, M.D Freehold
Mark Stem, M.D Cherry Hill
Robert J. Weierman, M.D South Orange
Michael E. Beams, D.O., Consultant Cranford
Louis Scibetta, Consultant Princeton
Committee on Retirement Plan for Physicians
(Staff Liaison, Joseph C. Lucci)
Nicholas E. Marchione, M.D., Chairman Vinelam
Paul J. Kreutz, M.D Elizabeth
Jack William P. Love, M.D Woodbur
Henry J. Mineur, M.D Westfief
Robert E. Steward, M.D North Brunswic'
SPECIAL COMMITTEE TO
COUNCIL ON MEDICAL SERVICES
Committee on Occupational Health, Worker’s
Compensation, and Rehabilitation
(Staff Liaision, Joseph C. Lucci)
George P. Bisgeier, M.D., Chairman Newar
Andrew G. Hudacek, M.D., Vice-Chairman Morristowj
J. Campbell Howard, M.D Mountainsid
Michael N. Jennings, M.D Somervil)
Bertram M. Kummel, M.D Morristowll
Edwin A Turner, Jr., M.D Upper Saddle Rive
Mathilda R Vaschak, M.D North Plainfielij
John S. Tobin, M.D., Consultant Princetoji
SPECIAL COMMITTEES TO
COUNCIL ON PUBLIC HEALTH
Committee on Cancer Control
(Staff Liaison, Joseph C. Lucci)
Benjamin F. Rush, Jr., M.D., Chairman Newar
Donald Brief, M.D Millbur
Sherman Garrison, M.D Bridgeto
George J. Hill, M.D Newar
Warren H. Knauer, M.D Hillsic
Abert A Pineda, M.D Clifto
Harvey Rothberg, M.D Princeto
Elissa J. Santoro, M.D Irvingto
Eva B. Stahl, M.D Highland Par
Harvey P. Yeager, M.D Millbur j
Committee on Child Health
(Staff Liaison, Joseph C. Lucci)
Glenn P. Lambert M.D., Chairman
James Q. Atkinson, M.D
Thomas F. Bejgrowicz, M.D
Anthony Brickman, M.D
William J. Farley, M.D
Harry E. Turse, M.D
Catherine P. Bush, Student Representative
LindeU
.... T rente'
Brief,
.... Medfoi!
Wood-Rid^i
Committee on Conservation of Vision
(Staff Liaison, Joseph C. Lucci)
Marc L. Engel, M.D., Chairman Holmd
Malcolm H. Bloch, M.D Morristow:
Afonse A Cinotti, M.D Jersey Ci
Samuel Diskan, M.D Atlantic Ci
Ivan H. Jacobs, M.D North Plainfie
Oram R Kline, Jr„ M.D Woodbu
Ralph A Skowron, M.D Cherry H
Saul M. Tischler, M.D Cherry H
Marc L. Engel, M.D., Consultant Holmd:
Ivan H. Jacobs, M.D., Consultant North Plainfiel
Committee on Environmental Health
(Staff Liaison, Joseph C. Lucci)
Philip J. G. Quigley, M.D.,
Chairman Point Pleasant Beat
Seymour Charles, M.D Maplewoc:
Stanley R Lane, M.D Moorestow
Richard H. Musgnug, M.D Medford Lakf
E. Spencer Paisley, M.D Haddon Heigh
William I. Weiss, M.D Livingstcj
Meyer T. Weissman, M.D Cranbu
Bradley S. Panton, Student
Representative New Brunswic
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
986
le IBM Personal Computer
tool for modern times
j the Medical Office.
!DI-SCAN®, an Authorized IBM® Value-
led Dealer for the Personal Computer
Comprehensive $8.995.00 MEDI-SCAN In-office
l g And Accountin g System Includes:
p IBM Personal Computer XT with 128K,
Megabyte hard disk.
2 IBM Graphics Printer.
)DI-SCAN software — customized for your
ctice, including procedure numbers for state
:ncies. Generates accounting reports,
nprehensive patient statements, insurance
1 third party forms.
tional electronic paperless billing to third party
jncies, where applicable.
lining— Complete in-office training for your staf
pport— “HOT-LINE” 800 number for
itinuous support.
IDI-SCAN Single Source
pport System
>I-SCAN’S unique, comprehensive hardware and software maintenance agreement guarantees continuing
ce and repair, system updates and additional customization, plus in-office training — all from one source. Our
training consultants and technicians are dedicated to giving you the best possible service.
Personal Computer XTs are in stock in our local warehouses ready to be immediately installed. Over three
ired physicians are using the MEDI-SCAN System — join them in making the IBM PC-XT “A tool for modem
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Networking available for group practices and clinics
wuld like to know more about the MEDI
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rvice centers currently in: New England • Mid Atlantic States • Mid Western States • California • Texas
EDI-SCAN is a registered trademark of PAL Assoc. Inc.
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)L. 81— NUMBER 11— NOVEMBER 1984
987
Statement of Ownership,
Management, and Circulation
(Required by 39 U.S.C. 3685)
1. Title of Publication: THE JOURNAL of the Medical Society of New Jersey.
1A. Publication No.: 0025-7524.
2. Date of Filing: September 28, 1984.
3. Frequency of Issue: Monthly.
3A No. of Issues Published Annually: 12 + 1 = 13.
3B. Annual Subscription Price: $20.00.
4. Location of Known Office of Publication: 2 Princess Road, Lawrenceville,
Mercer County, NJ 08648.
5. Location of the Headquarters or General Business Office of the Publisher:
2 Princess Road, Lawrenceville, Mercer County, NJ 08648.
6. Names and addresses of publisher, editor, and managing editor Pub-
lisher, Medical Society of New Jersey, 2 Princess Road, Lawrenceville, NJ 08648.
Editor, Arthur Krosnick, M.D., 2 Princess Road, Lawrenceville, NJ 08648. Man-
aging Editor, Geraldine R Hutner, 2 Princess Road, Lawrenceville, NJ 08648.
7. Owner (if owned by a corporation, its name and address must be stated
and also immediately thereunder the names and addresses of stockholders
owning or holding 1 percent or more of total amount of stock. If not owned
by a corporation, the names and addresses of the individual owners must be
given. If owned by a partnership or other unincorporated firm, its name and
address, as well as that of each individual must be given. If the publication
is published by a nonprofit organization, its name and address must be
stated.): Medical Society of New Jersey, 2 Princess Road, Lawrenceville, NJ
08648 (a nonprofit corporation of New Jersey).
8. Known bondholders, mortgages, and other security holders owning or
holding 1 percent or more of total amount of bonds, mortgages, or other
securities: none (a nonprofit corporation of New Jersey).
9. For completion by nonprofit organization authorized to mail at special
rates (Section 41 1.3, DMM only). The purpose, function, and nonprofit status
of this organization and the exempt status for federal income tax purposes
have not changed during preceding 12 months.
10. Extent and nature of circulation:
Extent and nature of circulation
A Total no. copies printed (net press run)
B. Paid circulation
1. Sales through dealers and carriers,
street vendors, and counter sales
2. Mail subscriptions
C. Total paid circulation (sum of B1 and B2)
D. Free distribution by mail carrier or other means-
samples, complimentary, and other free copies
E. Total distribution (sum of C and D)
F. Copies not distributed
1. Office use, left-over, unaccounted, spoiled after
printing
2. Return from new agents
G. Total (sum of E, FI, and 2 — should equal net press
run shown in A)
Actual
no. of
copies of
Average single
no. copies issue
each issue published
during nearest
preceding to filing
12 months date
11,500 10,600
9,605
9,755
9,605
9,755
1,671
609
11,276
10,364
224
236
11,500
10,600
11. I certify that the statements made by me above are correct and complete.
(signed) Arthur White
Director of Finance and Administrative Services
12. For completion by publishers mailing at the regular rates (Section
132.121, Postal Service Manual). 39 U.S.C. 3626 provides in pertinent part: “No
person who would have been entided to mail matter under former section 4359
of this title shall mail such matter at the rates provided under this subsection
unless he files annually with the Postal Service a written request for per-
mission to mail matters at such rates." In accordance with the provisions of
this statute. 1 hereby request permission to mail the publication named in Item
1 at the phased postage rate presently authorized by 39 U.S.C. 3626 (signed).
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS'
988
"One of the main reasons I
iose to become a participating
ealthWays physician was because
HealthVVays basic philosophy of
ordinated patient care. As a spe-
ilist, this is of extreme importance
me. I work closely with my pa-
ints' primary care physicians who
low them intimately since they
e them on a regular basis. This
lysician cooperation delivers the
ost complete care possible
without duplication or disparities.
In addition, since HealthVVays
covers its members for surgical
procedures in the setting most
appropriate, I can even perform
simple surgery in my own office
when hospitalization really isn't
necessary. That makes inordinate
sense for many patients and for me.
There's a great deal of logic
to HealthVVays as a health plan.
And a great deal of logic for phy-
sicians to become participants."
To learn all the HealthVVays
benefits for you and your patients,
call Jon Marsicano, M.D., Vice
President, Medical Affairs, at
1-800-624-0720.
HealthWays
YOUR WAY TO BETTErVhEALTH CAR!
© 1984 HealthWays, Inc.
T)L. 81— NUMBER 11— NOVEMBER 1984
989
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual & electro-acupuncture and TENS, applicable toward the
200-hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
Dec. 14-16, 1984 and again the weekend of Feb. 1-3, 1985 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
official journal, Acupuncture & Electro-Therap. Res., Int.J. (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Research
Foundation and the Neuroscience Dept, of Long Island College
Hospital, Pharmacology Dept, of The Chicago Medical School.
Also eligible for AMA/CME credit. For information, contact Y.
Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC 10032. Tel:
(212) 781-6262 or (212) WA8-0658, or Saul Heller, M.D., Tel:
(212) 838-7514.
The Academy of Medicine of New Jersey
presents
a symposium on
Medical & Surgical Management of
Cerebrovascular Insufficiency
Saturday, November 17, 1984
8:00 a. m. -1:00 p.m.
at
UMDNJ-New Jersey Medical School, Newark
This course is intended for family physicians and surgeons,
internists and neurologists interested in the care of patients
with cerebrovascular insufficiency. In addition, these topics
will be of value to vascular technologists interested in Nonin-
vasive Vascular Laboratory testing.
LEARNING OBJECTIVE: To review the diagnostic and medi-
cal management of cerebrovascular insufficiency. To become
familiar with diagnostic testing to include the role of CT & NMR
scanning and noninvasive vascular laboratory studies. To be-
come familiar with the technical considerations and results of
extracranial to intracranial bypass and carotid endarterectomy
in the treatment of patients with cerebrovascular insufficiency.
To review and be familiar with the medical and surgical man-
agement of asystemic extracranial carotid occlusive disease.
For further information contact:
of New Jersey
EXECUTIVE OFFICES
The Academy of Medicine of New Jersey
Two Princess Road
Lawrenceville, NJ 08648
(609) 896-1717
NEW JERSEY SOCIETY
OF PATHOLOGISTS
34TH ANNUAL SLIDE SEMINA I
SATURDAY, NOVEMBER 17, 1984
AT
UMDNJ-RUTGERS MEDICAL SCHOOL
PISCATAWAY, NEW JERSEY
9:00 A. M. -1:00 P.M.
ON
SURGICAL PATHOLOGY OF THE BREAST: D I AG NO I
AND THERAPEUTIC IMPLICATIONS
SPEAKER:
Robert V.P. Hutter, M.D.
Chairman, Department of Pathology
St. Barnabas Medical Center, Livingston
Adjunct Professor of Pathology,
College of Physicians & Surgeons,
Columbia University
A wide variety of cases submitted by members will be (I
cussed. Members will receive slide sets and case histories*
limited number of slide sets are available to non-members r
$35.00.
OBJECTIVE: The program is designed for diagnostic surg i
pathologists. The objectives are to become familiar with sp<-
fic types of diagnostic problems and rare types of bret
cancer, to emphasize the clinical-pathological interactio.
and to discuss the role of the pathologist in the managem t
of patients with these types of lesions.
For Further Information Contact:
Cathy Gillmer, Executive Secretary
New Jersey Society of Pathologists
Two Princess Road, Lawrenceville, NJ 08648
Phone (609) 896-1717
The Academy of Medicine of New Jersey
presents
A SYMPOSIUM ON
CONTROVERSIES IN GERIATRIC:
on
WEDNESDAY, NOVEMBER 28, 1984
1:00 p.m. -5:00 p.m.
at
MSNJ HEADQUARTERS BUILDING
Lawrenceville, New Jersey
The symposium will identify specific medical and social pnj-
lems of the aged. In addition we plan to determine who sho i
be in charge of the elderly: a primary care physician, o j
specialist in geriatrics. Finally we plan to decide whether r
not geriatrics is a specialty of medicine. The program is i-
signed for internists, family practitioners, administrators f
long term care facilities and other interested professions
For further information contact:
EXECUTIVE OFFICES
The Academy of Medicine of New Jers/
Two Princess Road
Lawrenceville, NJ 08648
(201) 896-1717
of New Jersey
990
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI-
;ME Calendar
i
The following is a list of
continuing medical
education courses for the
next two months. Contact the
sponsoring organization for
further information.
LNESTHESIOLOGY
an.
2 Dinner Meeting
6-9 P.M. — Ramada Inn. Clark
(NJ State Society of
Anesthesiologists andAMNJ)
ARDIOLOGY
Itec.
8 Streptokinase and Percutaneous
Transluminar Angioplasty
12 noon — St. Mary’s Hospital,
Orange
(AMNJI
MEDICINE
tec.
4 AIDS
9 AM.— Holy Name Hospital,
Teaneck
(AMNJ)
4 Research in Group B
Streptococcal Disease
8:30-9:30 AM.— Newark Beth Israel
Medical Center
(Newark Beth Israel Medical
Center and AMNJ)
5 ATOS
9 AM. — Warren Hospital,
Phillipsburg
(AMNJ)
5 Clinical Abstract Meeting
1-5 P.M. —The Manor, West Orange
(Oncology Society of NJ and
AMNJ)
5 Endocrine Conferences
12 3:30-5 P.M.— Rotates between
19 Newark Beth Israel Medical Center,
26 University Hospital, United
Hospitals Medical Center, Newark,
and VA Medical Center,
East Orange
(Endocrinology Section and
AMNJ)
5 Medical Grand Rounds
12 12 noon-1 P.M. — Rutgers Medical
19 School, Medical Education Bldg.,
New Brunswick
(UMDNJ and AMNJ)
5 Medicine Morbidity and Mortality
Conference
8-9 AM.— Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
6 Management of Congenital
Infections
9 AM. — Freehold Area Hospital
(AMNJ)
6 Immunoregulation: Basic
1 3 Concepts and Applications
4- 6 P.M. —Institute for Medical
Research, Copewood St., Camden
(Institute for Medical Research
and AMNJ)
12 Clinical Immunology
I P.M .— VA Medical Center, Lyons
(AMNJ)
1 2 What Is New in Allergy?
8-9:30 P.M. —Schering Corporation,
Kenilworth
(NJ Allergy Society, Schering
Corp.. andAMNJ)
1 3 Management of Abdominal
Emergencies
I I AM — St. Joseph’s Hospital and
Medical Center, Paterson
(AMNJ)
13 The Prevention and Reversibility
of Heart Disease
12 noon-1 P.M.— Carrier
Foundation, Belle Mead
(Carrier Foundation and AMNJ)
13 Indications, Techniques, and
Results in Coronary Thrombolysis
5- 7:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
Jan.
2 Internal Medicine Review Course
9 3-6 P.M.— Overlook Hospital,
16 Summit
23 (Overlook Hospital and AMNJ)
30
2 Endocrine Conferences
9 3:30-5 P M — Rotates between
16 Newark Beth Israel Medical Center,
23 University Hospital, United
30 Hospitals Medical Center, Newark
and VA Medical Center,
East Orange
(Endocrinology Section and
AMNJ)
2 Medical Grand Rounds
9 12 noon-1 P.M.— Rutgers Medical
16 School, Medical Education Bldg.,
23 New Brunswick
30 (UMDNJ and AMNJ)
2 Medicine Morbidity and Mortality
Conference
8-9 A.M. — Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ and AMNJ)
2 Immunoregulation: Basic
1 0 Concepts and Applications
17 4-6 P.M. — Institute for Medical
24 Research, Copewood St., Camden
31 (Institute for Medical Research
and AMNJ)
8 Melanoma Precursors
8-10 P.M. —Schering Corp.,
Kenilworth
(NJ Dermatological Society and
AMNJ)
8 AIDS
8-9 AM — Wayne General Hospital
(AMNJ)
9 AIDS
1-2 P.M.— VA Hospital, Lyons
(AMNJ)
1 5 Cocaine Abuse
12 noon— St. Maiy’s Hospital,
Orange
(AMNJ)
16 Dermatological Conference
6-8 P.M.— Rutgers Community
Health Plan, U.S. Hwy. 1 & Rt. 18,
New Brunswick
(UMDNJ -Rutgers Medical School
and AMNJ)
17 New Concepts in Digoxm
Metabolism
1 1 AM - 12 noon— St. Joseph’s
Hospital, Paterson
(St Joseph's Hospital and Medical
Center and AMNJ)
17 Geriatrics
3 P.M. — Ancora Psychiatric
Hospital, Hammonton
(AMNJ)
17 Whither Multiple Sclerosis?
5-7:30 P.M.— Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
30 Mitral Valve Prolapse
1 -2:30 P.M .— VA Medical Center,
Lyons, Bldg. 93
(VA Medical Center and AMNJ)
NEUROLOGY/PSYCHIATRY
Dec.
3 Survival Guilt with Somatic
Symptoms
8: 1 5- 1 0:30 P.M.— 4 Garden Place,
N utley
(Essex Psychiatric Seminar and
AMNJ)
3 When the Patient Abuses Drugs:
Skills for the Outpatient Therapist
1 -4 P.M. —Fair Oaks Hospital,
Summit
(Fair Oaks Hospital andAMNJ)
6 Medical Hypnosis Course
13 4-8 P.M. —Carrier Foundation.
Belle Meade
(Carrier Foundation andAMNJ)
12 Sleep Disorders
1:30-2:30 P.M. —Rutgers
Community Health Plan, 57 U.S.
Hwy. #1, New Brunswick
(Rutgers Community Health Plan
and AMNJ)
1 3 Becoming a Psychotherapist
12 noon- 1 P.M.— Carrier
/OL. 81— NUMBER 11— NOVEMBER 1984
991
American Society For Parenteral & Enteral Nutrition®
9TH CLINICAL CONGRESS
January 21-24, 1985
FONTAINEBLEAU HOTEL
MIAMI BEACH, FLORIDA
For more information contact: A S P E N., 8605 Cameron Street, Suite
500, Silver Spring, MD 20910, (202) 638-5881.
1985 CME CRUISE/CONFERENCES ON SELECTED
MEDICAL TOPICS
Caribbean, Mexican, Hawaiian, Alaskan, Mediter-
ranean. 7-14 days year-round. Approved for 20-24 CME
Cat. 1 credits (AMA/PRA) & AAFP prescribed credit.
Distinguished professors. FLY ROUNDTRIP FREE ON
CARIBBEAN, MEXICAN, & ALASKAN CRUISES.
Execellent group fares on finest ships. Registration limited.
Pre-scheduled in compliance with present IRS require-
ments.
Information: International Conferences, 189 Lodge
Ave., Huntington Station, N.Y. 11746. (516) 549-0869.
PEDIATRIC UPDATE 1985
Hotel de Paris, Monte Carlo, Monaco
March 16-24, 1985
Sponsored by: Department of Pediatrics, Schneide
Children’s Hospital, Long Island Jewish-Hillside Medi
cal Center, New Hyde Park, NY. Faculty: Philij
Lanzkowsky, M.D., Jean Alexander Cortner, M.D., Jan
G. Schaller, M.D., and Irving Schulman, M.D. Credits
21 hours Category 1 ACCME, AMA and AAFP.
Information: Continuing Education Coordinator, Lon
Island Jewish-Hillside Medical Center, New Hyde Park
NY 11042, (718) 470-2114.
V LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
WEDNESDAY, DECEMBER 5, 1984
HYPERTENSION
MODERATOR: DAVID T. LOWENTHAL, M.D
3:00 Case Presentation
3:30 Should Mild Hypertension be Treated?
4:00 What is the Step-Care Management?
4:30 Managing Hypertensive Emergencies
5:00 Managing Resistent Hypertension: What are the
Benefits of Antihypertensive Therapy?
M.D.
Stanley Spitzer,
M.D.
Sheldon R. Bender,
M.D.
David T. Lowenthal,
M.D.
Stuart Snyder,
M.D.
David T. Lowenthal,
M.D.
LECTURE HALL “A”— 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
**WINE & CHEESE SERVED FOLLOWING CONFERENCE**
992
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
Foundation, Belle Meade
(Carrier Foundation and AMNJ)
Child Sexual Abuse
8:30 AM. -5 P.M. —Fair Oaks
Hospital, Summit
(Fair Oaks Hospital and AMNJ)
I Coordination of Psychiatric
Treatment in the Hospital and
Community
3 P.M.— Ancora Psychiatric
Hospital, Hammonton
(Ancora Psychiatric Hospital)
Lecture Series
8:30- 1 0:30 PM— 30 1 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
th.
Case Seminars and Supervision to
Improve Psychotherapeutic
Techniques
8-10 P.M.— 310 Harding Dr., South
Orange
(Advanced Psychiatric Study
Group and AMNJ)
Sexual Obsession in a 20-Year
Marriage
8: 1 5- 1 0:30 P.M.— 1 1 1 Ridgewood
Ave„ Glen Ridge
(Essex Psychiatric Seminar and
AMNJ)
Neurology: New Treatments of
Cerebrovascular Disease
2 P.M.— John E. Runnells Hospital,
Berkeley Heights
(AMNJ)
21 Lecture Series
8:30- 1 0:30 P.M. —30 1 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
OBSTETRICS/GYNECOLOGY
Dec.
3 Prophylactic Mastectomy and
Treatment of the Second Breast
8 AM. -5 P.M. — UMDNJ-Rutgers
Medical School, Medical Education
Bldg., New Brunswick
(UMDNJ-Rutgers Medical School)
4 Psychosocial Issues and
Interactions in Breast Disease
9 AM. -4 P.M. — UMDNJ-Rutgers
Medical School, Medical Education
Bldg., New Brunswick
(UMDNJ-Rutgers Medical School)
PEDIATRICS
Jan.
1 1 Extracorporeal Membrane
Oxygenation for Neonatal
Respiratory Failure
8-9:30 AM.— Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
RADIOLOGY
Dec.
5 NMR— Clinical Imaging
1:30 P.M. —Essex County Hospital
Center, Cedar Grove
(AMNJ)
1 5 Topic To Be Announced
7:30-10 P.M.— Saint Barnabas
Medical Center, Livingston
(NJ Institute of Ultrasound in
Medicine and AMNJ)
20 Radiology Meeting
7:30 P.M. —Saint Barnabas Medical
Center, Livingston
(Radiological Society of NJ and
AMNJ)
27 Visiting Professorship Program
1 :30-5 P.M —Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center
and AMNJ)
Jan.
1 6 Combined Modality Therapy in
the Treatment of Unresectable
Carcinoma of the Pancreas
6:30-10 P.M. —The Manor, West
Orange
(Radiotherapy Section and AMNJ)
1 7 Multimodality Approach to Renal
Disease
7:30-10 P.M. — Saint Barnabas
Medical Center, Livingston
(NJ Institute of Ultrasound in
Medicine and AMNJ)
SURGERY
Dec.
1 Clinical Meeting
All Day Session— UMDNJ-NJ
Medical School, Newark
(NJ Chapter, American College of
Surgeons and AMNJ)
6 Surgical Treatment of Morbid
Obesity
12 noon— West Jersey Hospital,
Camden
(AMNJ)
14 Surgical Emergencies in the
Newborn
8-9:30 AM.— Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
18 Arterial Clot Lysis Using
Streptokinase
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
Jan.
22 Malignant Hyperthermia
8- 1 0 P.M. —Englewood Club.
Englewood
(Englewood Surg. Soc. and AMNJ)
MISCELLANEOUS
Dec.
5 DRG— Cost Containment
10:30 AM.— St. Mary's Hospital,
Passaic
(AMNJ)
29 Nuclear Holocaust Prevention
12 noon-1 P.M. —Carrier
Foundation, Belle Meade
(Carrier Foundation and AMNJ)
COME JOIN US
The 219th Annual Meeting
Medical Society of New Jersey
Americana Host Farm Resort
Lancaster, Pennsylvania
May 2-5, 1985
i
JL. 81— NUMBER 11— NOVEMBER 1984
993
r
CLIP & SA'
The Medical Society of New Jersey
and the Healthcare Information Network
Television Program Guide
September-May
Closed circuit television programs related to issues and concerns of physician members of MSNJ.
• PRESIDENT’S FORUM: hosted by Frank Y. Watson, M.D., President, MSNJ
• THE IMPAIRED PHYSICIAN: hosted by David I. Canavan, M.D., Director,
Impaired Physicians Program, MSNJ
• STATE OF THE ART: hosted by Howard D. Slobodien, M.D., Past President, MSNJ
Programs will be featured the first, second, and third Tuesday of each month at 1:00 p.m. There will i
an 800 number for viewer participation.
Presented solely through those New Jersey hospitals which are subscribers to the HIN closed circ
television network. A listing of participating hospitals is on the bottom of this page.
For additional information or comments, contact the Medical Society of New Jersey, Department of Spec
Projects, A. Ronald Rouse, Director.
President’s Forum
Frank Y. Watson, M.D., President of
the Medical Society of New Jersey,
will host this program with selected
members from the Board of Trustees
and appropriate Council and Commit-
tee Chairpersons who will present in-
formation discussed at the previous
Board meetings.
Air time for this program is financed
by the Medical Society of New Jersey.
Tuesday, October 2, 1984
Tuesday, November 6, 1984
Tuesday, December 4, 1984
Tuesday, January 1, 1985
Tuesday, February 5, 1985
Tuesday, March 5, 1985
Tuesday, April 2, 1985
Tuesday, May 7, 1985
The impaired Physician
Air time for this program is financed
by the Health Care Insurance Ex-
change (HCIE) and the Princeton In-
surance Company (PIC).
Tuesday, September 11, 1984
“Acute Case of the
Impaired Physician”
Tuesday, October 9, 1984
“Rehabilitation Programs”
Tuesday, November 13, 1984
"Aftercare”
Tuesday, December 11, 1984
“The Family and The Disease ”
Tuesday, January 8, 1985
“Support Groups”
Tuesday, February 12, 1985
“Problems of Re-Entry”
Tuesday, March 12, 1985
“Followup/Monitoring”
Tuesday, April 9, 1985
“Recidivism/Special Problems”
State of the Art
Air time for this program is finann
by the Medical Society of New Jen
Tuesday, October 16, 1984
Professional Liability
James E. George, M.D., J.D.
and
Mr. Adam Wilczek
Tuesday, November 20, 1984 *
Continuing Medical Education
Paul Hirsch, M.D.,
Edwin Messey, M.D.
and
Robert Rigolosi, M.D.
Tuesday, December 18, 1984
MSNJ Legislative Activities
Mr. Joseph Katz
and
Mr. Clark Martin
The following programs will be r
nounced at a later date:
Tuesday, January 15, 1985 '
Tuesday, February 19, 1985
Tuesday, March 19, 1985
Tuesday, April 16, 1985 i
Tuesday, May 21, 1985
Participating Hospitals*: Beth Israel Hospital; Freehold Area Hospital; Memorial General Hospital; Mi-
ristown Memorial Hospital; Northern Ocean Hospital System, Inc.; Pascack Valley Hospital; Saint Elizabn
Hospital; Saint Mary’s Hospital; Saint Peter’s Medical Center; and Underwood-Memorial Hospital.
Hospitals Declaring a Preliminary Interest: Atlantic City Medical Center; ACMC-Mainland Division; Be/
Bacharach Rehab. Hospital; Bridgeton Hospital; Carrier Foundation; Clara Maass Medical Center; Co-
munity Memorial Hospital; Deborah Heart & Lung Center; Englewood Hospital Association; Hackensext
Medical Center; Holy Name Hospital; Hospital Center at Orange; John F. Kennedy Medical Ctr.; KMH/UMi
Stratford Division; Kessler Institute for Rehab.; Monmouth Medical Center; Muhlenberg Hospital; New«k
Beth Israel Medical Ctr.; Newton Memorial Hospital; Riverside Hospital; Salem County Memorial Hospi I;
and Saint Clare’s Hospital; Saint Francis Medical Center; Warren Hospital; West Hudson Hospital; and W it
Jersey Hospital-Northern Division.
‘Listing of hospitals may have changed since this printing.
CLIP & S/E
994
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS f
IETTERS TO THE
1DITOR
I
i
Actinomycosis; Faithful
Vorker; Length of Stay
— *
i
l
i ctinomycosis
August 20, 1984
[ ar Doctor Krosnick
|[ would like to report two pediatric
t ses of thoracic actinomycosis, an
itcommon entity.
1. An eight-year-old male was in
jod health until he fell onto the
1 ndlebars of his bicycle producing
; abrasion of his left lateral thorax,
jin and erythema developed and
ten he visited the surgical clinic
[here a debridement was per-
i Tried. He returned two weeks later
cause of drainage at the site. A
lture and smear were obtained,
le smear revealed sulfur granules
long the pus cells. He was ad-
itted and started on intravenous
gh-dose penicillin; 1,000,000
pits IV q 6h. The culture grew Ac-
tomyces israelii. Drainage con-
hued and x-ray examination
I towed a progressive empyema He
en underwent a thoracotomy
lich led to a rapid resolution of the
ipyema He was discharged and
ntinued on oral phenoxymethyl
nicillin 250 mg q 6h for one
onth. Followup chest x-rays and
lysical examination documented
mplete recovery.
2. A 13-year-old male who has
iffered from psychomotor retarda-
)n from birth was noted on physi-
cal examination to have a cystic
mass of the left chest wall. A chest
x-ray showed a pleural empyema A
thoracotomy was performed and
chest tubes were placed for
drainage. A gram stain of the ma-
terial obtained at surgery showed
sulfur granules and cultures grew
Actinomyces species. He was placed
on high-dose intravenous penicillin;
1,000,000 units IV q 4h for two
weeks and showed gradual improve-
ment. He was continued on oral
phenoxymethyl penicillin 250 mg po
q 6h for six weeks with subsequent
complete resolution of the pleural re-
action.
The second patient had the poor
dental hygiene and malnutrition
that has been associated with
pulmonary infection with ac-
tinomycosis. The appearance of the
mass was consistent with the “tun-
neling” described with ac-
tinomycosis’s disregard of tissue
planes.13 Mass lesions have been re-
ported in other cases.3 The first pa-
tient was unusual in that infection
had apparently spread from the skin
to the pleura He had been in other-
wise excellent health previously.
Both patients’ management re-
quired the placement of chest tubes
which usually are not required in
treating this entity. In previous re-
ports, the length of treatment with
oral penicillin following high-dose
intravenous penicillin had not been
well established.
(signed) Robert B. Baker, M.D.
REFERENCES
1. Rose HD, Varkey B, Kesevan KCP:
Thoracic actinomycosis caused by Ac-
tinomyces meyeri. Am Rev Resp Dis
125:251-254, 1982.
2. Spinola SM, Bell RA Henderson FW:
Actinomycosis. Am J Dis Child
135:336-339, 1982.
3. Seaman WB: The case of the in-
fected lung. Hosp Prac 23-26, 1982.
4. Harrison RN, et. al.: Acute ac-
tinomycotic empyema. Thorax
34:406-407, 1982.
5. Stanley TV: Deep actinomycosis in
childhood. Acta Ped Scand 69:173-176,
1982.
Faithful Worker
August 23, 1984
Dear Doctor Krosnick
I would like to call to your atten-
tion an item I think merits notice.
Joan Basic is Executive Secretary
of Bergen County Medical Society
and has worked faithfully in the
Bergen County vineyard for more
than 13 years. We just have been
notified by the American Society of
Association Executives of Washing-
ton, D.C., that the ASAE Certifica-
tion Commission has presented her
with the Certified Association Ex-
ecutive Award.
To put this in the proper per-
spective, let me point out that there
are 825 members of the American
Association of Medical Society Ex-
ecutives, but only 34 are CAEs. And,
indeed, there are no medical ex-
ecutives in New Jersey who have
achieved CAE status. The examin-
ation itself is a grueling affair and
takes a whole day. Most of the execs
who stand for the examination
usually study for two years in ad-
vance.
Mrs. Basic also is the paid Ex-
ecutive Secretary of our Bergen
County Auxiliary. To the best of my
knowledge, she is the only paid
County Auxiliary exec in the coun-
try.
We obviously are justly proud of
Mrs. Basic's accomplishments.
(signed) George Willis
Executive Director
Bergen County Medical Society
Length of Stay
September 10, 1984
Dear Doctor Krosnick
I have noticed a disturbing trend
among physicians; more and more
of them are equating quality of care
in hospitalized patients with the
length of stay in the hospital. The
shorter the stay, the better the quali-
ty of care. Of all the people, phy-
sicians are accepting this myth as
gospel. In almost any medical meet-
ing, some physicians will get up and
describe, in very flowery language,
how in a certain diagnosis the hos-
pital stay was reduced by half a day
or so and will give a pat on the back
of the medical staff for raising the
quality of patient care.
With the onslaught of PSROs,
PROs, HMOs, DRGs, and all the
other abbreviated modalities of
medical interferences, abbreviated
stay in the hospital does not neces-
sarily mean better quality of patient
care. In some cases, an extra day or
two in the hospital actually can im-
prove the standard of life and health
of the patient. Suddenly, we are
being exposed to too much adminis-
trative medicine.
(signed) Jagdish C. Dang, M.D.
)L. 81— NUMBER 11— NOVEMBER 1984
995
Book Reviews
Breast Cancer; Classics of
Cardiology; Handbook of
Pediatric Primary Care
Breast Cancer: Diagnosis
and Management, Vol. 1
Gianni Bonadonna, M.D., (ed). New
York NY, John Wiley & Sons, 1984.
Pp. 347. Illustrated,
Dr. Bonadonna of the National
Tumor Institute in Milan has
gathered an impressive array of
European and American cancer
specialists; they have contributed a
total of 17 chapters which purport
to cover practically every aspect of
the diagnosis and management of
breast cancer from basic biology and
pathology to surgery, chemotherapy,
radiotherapy, and psychology.
Their stated aim was to provide a
“distillation of current results” but
unfortunately they produced a tedi-
ous textbook containing a volumi-
nous amount of detailed infor-
mation, much of which is only semi-
distilled, if not raw.
Most clinicians who periodically
assume a degree of responsibility for
the diagnosis and management of
this most common type of cancer
readily would welcome a book con-
taining the latest information, but
this mistura of facts, opinions, and
research findings tends to confuse,
overwhelm, and even discourage
those readers who already are not
knowledgeable in their own specific
areas of expertise.
The present volume, the first in a
series dealing with cancer, cannot
be recommended to anyone but the
most sophisticated physician.
Jerome Abrams, M.D.
Classics of Cardiology,
Volume Three
Callahan, Keys, and Key (eds).
Malabar, FL, Robert Krieger Pub-
lishing Co., 1983. Pp. 623. Il-
lustrated.
Classics in Cardiology, Volume 3
is a collection of 47 selected research
manuscripts published between
1895 and 1954; the theme of these
papers is cardiovascular diseases.
Though many of the authors of
these papers are recognized as ven-
erable physician-scientists, some
are not recognized readily; however,
the nature of the contribution to
medical science is in all cases.
The editors have prepared brief
biographies of these authors. These
vignettes acquaint the reader with
the author and provide some
framework for the significance of
the research article then presented.
The student of medical history will
see these biographies as starting
points for more indepth study. Of
interest was the availability of the
birth date for deriving the scientists’
ages at the times of their significant
contributions. The manuscripts are
presented chronologically from the
oldest (1895) to most recent (1954).
The last three pages before the
author index consist of a section of
key references entitled, “History of
Cardiology,” providing additional
sources for the person interested in
further reading.
To what group of readers is this
book directed? Individuals within
the medical sciences who are history .
buffs certainly will want to read this
book. Laypeople doing background
medical science historical research,
e.g. journalists, may find the book
useful but not the manuscripts. The
book might be useful as a text for
studying protocol methodology and
how it has or has not evolved over
the past 90 years. Finally, this bo<
is ideal as a reference text in tl
medical library for the informatu
contained will not be out-of-da
next year.
Robert M. MacMillan, M.
Handbook of Pediatric
Primary Care,
Second Edition
Chow, Durand, Feldman, and Mi
New York, NY, John Wiley & So
1984. Pp. 1,300. ($36.95)
The purpose of this book is
provide concise primary care pe
atric information in handbook stj
The authors, all nurses, h;
directed their efforts primarily
pediatric nurse practitioners.
The book is divided into par
Part one focuses on assessment a
management of the healthy ch
part two addresses assessment a
management of common clini
problems. The information is p
sented in a straightforward manr
with enough prose to compleme
extensive outlines covering essent
information. In each chapter, t
authors enhance their pres<
tations with many tables fr<
classical texts and articles in t
pediatric literature, e.g. Tanner a
developmental staging.
The strength of this text is
provide primary health c<
workers, especially nurses, w
ample reference sources, biblii
raphies, and charts. Emphasis
placed on diagnosis and supp
counseling of the child/parent dy
The weakness in a book of tl
nature is the lack of therapeu
specifics, which for the most p
are mentioned in a general sense,
exception is the treatment of i
naiy tract infections which is rati
complete. Being an “updated” s
ond edition, some of the bibliog
phy is stale by dates. Mention
made of Probana and Neomulls
formulas (now off the market). M
tiple pressure TB testing by H
test is obsolete. The etiology of pm
monia by Streptococcus pni
moniae and Diplococcus pw
moniae is redundant.
The book is handsomely bound
black with gold lettering and
analogous in appearance to a slig
ly larger version of our friend, 7
Merck Manual.
Frank C. Vanore, M
996
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS1
m
y
■wm-
:•'■?• is.
y--X'
New studies
uncover the
potassium effects of
beta-2 blockade
Clinical pharmacology
data from the
New England Journal
of Medicine:
"... when normal young men are given infu-
sions of epinephrine at levels such as those
that circulate in patients with myocardial
I infarction, their serum potassium concen-
trations fall by about 0.8 mmol per liter.
Hypokalemia is prevented by... beta-2
blockade."'
INDERAL
(propranolol HCI)
prevented beta-2
mediated hypokalemia
In a pharmacological study comparing
INDERAL with atenolol, 10 hypertensive
patients were infused with the nonselective
beta agonist, isoproterenol, which also
stimulates beta-2 mediated hypokalemia.
At doses high enough to overcome beta-1
mediated heart rate reductions, the hypo-
kalemia caused by isoproterenol was
blunted by INDERAL, but not by atenolol.2
INDERAL compared with atenolol:
change in plasma potassium after
beta-agonist infusion2
3.5 7 14 35 70
ng/kg 1 min '
INDERAL tablets, 80 mg qid
Atenolol, 100 mg qd
No beta blockade
-adapted from
Vincent et al, p 1122
Please see last page for brief summary of prescribing information.
'I
. ■
' w '
Epinephrine-
induced hypokalemi,
can intensify
diuretic-induced
hypokalemia
i
IL
f- r-">
From the Lancet:
Epinephrine-induced
hypokalemia can cause
ECG abnormalities
typical of other forms
of hypokalemia
In a study of the effects of epinephrine-
induced hypokalemia on the electro-
cardiogram, it was shown that levels of
plasma epinephrine similar to those
observed during myocardial infarction
can produce changes in ventricular re-
polarization, which are reflected in
T-wave flattening and QT prolonga-
tion in normal subjects.5
In clinical pharmacology studies of hyper-
tensive and normal patients, epinephrine-
induced hypokalemia was prevented by
beta-2 blockade.2 4
Please see last page for brief summary of prescribing information.
"Although both diuretics and adrenaline are
known to cause hypokalaemia , we believe
that this is the first demonstration that these
two factors can act in an additive manner.
Routine monitoring of serum potassium in
patients on thiazide diuretics may under-
estimate the risks of hypokalaemia."3
Epinephrine drives potassium into cells—
an effect that has been shown to be under
beta-2 receptor control4; thiazides promote
excretion of potassium. When these ac-
tions occur together, hypokalemia can
intensify significantly.3
Once-daily INDERAL LA
(propranolol HCI) for
smooth blood pressure
control without the
potassium problems
of diuretics
Patients with "uncomplicated" hyper-
tension may develop ventricular
arrhythmias in the presence of hypo-
kalemia.6 Once-daily INDERAL LA
maintains smooth blood pressure reduc-
tions without a negative effect on serum
potassium and provides patients with
broad cardiovascular benefits-all in
a convenient daily dose.
Like conventional INDERAL tablets,
INDERAL LA should not be used in the
presence of congestive heart failure, sinus
bradycardia, heart block greater than first
degree, and bronchial asthma.
And for lifetime
benefits in foundation
treatment of angina
Once-daily INDERAL LA provides 24-hour
control of angina symptoms-plus the
cardiovascular benefits of the world's lead-
ing beta blocker. And unlike calcium
channel blockers, INDERAL LA, alone or
with a nitrate, is recommended for first-line
treatment of stable angina.
Simply start new patients on 80 mg
INDERAL LA once daily. Dosage may
be increased to 160 mg once daily to
achieve maximal control.
LONG ACTING
CAPSULES
The appearance of these capsules is a registered trademark of Ayerst Laboratories.
Please see last page for brief summary of prescribing information
III
80 mg 120 mg 160 mg
INDERAL
mmaam TABLETS
I Ri> 0
ng 20 mg 40 m
appearance of these tabli
Once daily
9
10 mg 20 mg 40 mg 60 mg 80 mg 90 mg
The appearance of these tablets is a registered trademark of Ayerst Laboratories.
(PROPRANOLOL HCI)
V M so
lALIJ
Q
120
[ J
160 (l i
LA mg
«=-~a
mg
mg
LONG ACTING
W
CAPSULES
The appearance of these capsules is a registered trademark of Ayerst Laboratories.
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULARS.)
INDERAL’ (propranolol hydrochloride) Tablets and Injectable
INDERAL’ LA (propranolol hydrochloride) Long Acting Capsules
INDICATIONS AND USAGE— INDERAL Tablets
Hypertension: INDERAL (propranolol hydrochloride) is indicated in the management of
hypertension It may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic INDERAL is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL is indicated for the
long-term management of patients with angina pectoris
Cardiac Arrhythmias:
1 ) Supraventricular arrhythmias
a) Paroxysmal atrial tachycardias, particularly those arrhythmias induced by cate-
cholamines or digitalis or associated with the Wolff-Parkinson-White syndrome. (See W-P-W
under WARNINGS.) b) Persistent sinus tachycardia which is noncompensatory and impairs
the well-being of the patient, c) Tachycardias and arrhythmias due to thyrotoxicosis when
causing distress or increased hazard and when immediate effect is necessary as ad|unctive,
short term (2-4 weeks) therapy May be used with, but not in place of, specific therapy. (See
Thyrotoxicosis under WARNINGS.) d) Persistent atrial extrasystoles which impair the well-
being of the patient and do not respond to conventional measures, e) Atrial flutter and
fibrillation when ventricular rate cannot be controlled by digitalis alone, or when digitalis is
contraindicated
2 ) Ventricular tachycardias
Ventricular arrhythmias do not respond to propranolol as predictably as do the supra-
ventricular arrhythmias a)Ventricular tachycardias With the exception of those induced by
catecholamines or digitalis, INDERAL is not the drug of first choice In critical situations when
cardioversion technics or other drugs are not indicated or are not effective, INDERAL may be
considered If, after consideration of the risks involved, INDERAL is used, it should be given
intravenously in low dosage and very slowly. (See DOSAGE AND ADMINISTRATION ) Care in
the administration of INDERAL with constant electrocardiographic monitoring is essential as
the tailing heart requires some sympathetic drive for maintenance of myocardial tone b)
Persistent premature ventricular extrasystoles which do not respond to conventional mea-
sures and impair the well-being of the patient
3 ) Tachyarrhythmias of digitalis intoxication
If digitalis-induced tachyarrhythmias persist following discontinuance of digitalis and cor-
rection of electrolyte abnormalities, they are usually reversible with oral INDERAL Severe
bradycardia may occur (See OVERDOSAGE ) Intravenous propranolol hydrochloride is
reserved for life-threatening arrhythmias Temporary maintenance with oral therapy may be
indicated (See DOSAGE AND ADMINISTRATION in the package circulars )
4.) Resistant tachyarrhythmias due to excessive catecholamine action during anesthesia
Tachyarrhythmias due to excessive catecholamine action during anesthesia may some-
times arise because of release of endogenous catecholamines or administration of cate-
cholamines. When usual measures fail in such arrhythmias, INDERAL may be given
intravenously to abolish them All general inhalation anesthetics produce some degree of
myocardial depression Therefore, when INDERAL (propranolol hydrochloride) is used to
treat arrhythmias during anesthesia, it should be used with extreme caution and constant
ECG and central venous pressure monitoring (See WARNINGS )
Myocardial Infarction: INDERAL is indicated to reduce cardiovascular mortality in
patients who have survived the acute phase of myocardial infarction and are clinically stable.
Migraine: INDERAL is indicated for the prophylaxis of common migraine headache The
efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL is useful in the management of hyper-
trophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL also improves exercise performance The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta receptor stimulation
Clinical improvement may be temporary.
Pheochromocytoma: After primary treatment with an alpha-adrenergic blocking
agent has been instituted, INDERAL may be useful as adjunctive therapy if the control of
tachycardia becomes necessary before or during surgery
It is hazardous to use INDERAL unless alpha-adrenergic blocking drugs are already in
use, since this would predispose to serious blood pressure elevation. Blocking only the
peripheral dilator (beta) action of epinephrine leaves its constrictor (alpha) action
unopposed.
In the event of hemorrhage or shock, there is a disadvantage in having both beta and
alpha blockade since the combination prevents the increase in heart rate and peripheral
vasoconstriction needed to maintain blood pressure.
With inoperable or metastatic pheochromocytoma, INDERAL may be useful as an adjunct
to the management of symptoms due to excessive beta receptor stimulation
INDICATIONS AND USAGE— INDERAL LA Long Acting Capsules
Hypertension: INDERAL LA (propranolol hydrochloride) is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihyperten-
sive agents, particularly a thiazide diuretic INDERAL LA is not indicated in the management
of hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated for
the long-term management of patients with angina pectoris
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-in-
duced angina, palpitations, and syncope INDERAL LA also improves exercise perfor-
mance The effectiveness of propranolol hydrochloride in this disease appears to be due to a
reduction of the elevated outflow pressure gradient which is exacerbated by beta-receptor
stimulation Clinical improvement may be temporary
CONTRAINDICATIONS. INDERAL and INDERAL LA are contraindicated in 1) car-
diogenic shock, 2) sinus bradycardia and greater than first degree block; 3) bronchial
asthma; 4) congestive heart failure (see WARNINGS) unless the failure is secondary to a
tachyarrhythmia treatable with INDERAL.
i
WARNINGS. CARDIAC FAILURE Sympathetic stimulation may be a vital componi| i
supporting circulatory function in patients with congestive heart failure, and its inhibition [
beta blockade may precipitate more severe failure Although. beta blockers should j
avoided in overt congestive heart failure, if necessary, they can be used with close follow-
in patients with a history of failure who are well compensated and are receiving digitalis a
diuretics Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis i
heart muscle
IN PATIENTS WITFIOUT A HISTORY OF HEART FAILURE, continued use of beta block,
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of he
failure, the patient should be digitalized and/or treated with diuretics, and the respor
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation c
angina and, in some cases, myocardial infarction, following abrupt discontinuance c
INDERAL (propranolol hydrochloride) therapy. Therefore, when discontinuance c
INDERAL is planned the dosage should be gradually reduced over at least a few weeks
and the patient should be cautioned against interruption or cessation of therapy withou
the physician's advice If INDERAL therapy is interrupted and exacerbation of angm.
occurs, it usually is advisable to reinstitute INDERAL therapy and take other measure
appropriate for the management of unstable angina pectoris Since coronary arter.
disease may be unrecognized, it may be prudent to follow the above advice in patient
considered at risk of having occult atherosclerotic heart disease who are given pro.
pranolol for other indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECE
BETA BLOCKERS. INDERAL should be administered with caution since it may block bi
chodilation produced by endogenous and exogenous catecholamine stimulation of b
receptors
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking ther
prior to ma|or surgery is controversial It should be noted, however, that the impaired abilit
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthe)'
and surgical procedures
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agonists
its effects can be reversed by administration of such agents, e g , dobutamine or
proterenol. However, such patients may be subject to protracted severe hypotens1
Difficulty in starting and maintaining the heartbeat has also been reported with b
blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes!
acute hypoglycemia in labile insulin-dependent diabetes In these patients, it may be nr
difficult to adjust the dosage of insulin.
THYROTOXICOSIS Beta blockade may mask certain clinical signs of hyperthyroidi
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of syi
toms of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid fi1
tion tests
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have b
reported in which, after propranolol, the tachycardia was replaced by a severe bradyca
requiring a demand pacemaker In one case this resulted after an initial dose of 5
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients
impaired hepatic or renal function INDERAL is not indicated for the treatment of hyperten
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Patii
should be told that INDERAL may interfere with the glaucoma screening test. Withdr;
may lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dise,
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re
pine should be closely observed if INDERAL is administered The added catecholarr
blocking action may produce an excessive reduction of resting sympathetic nervous act
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks
orthostatic hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals f
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studit,
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidenci
significant drug-induced toxicity There were no drug-related tumorigenic effects at ar
the dosage levels Reproductive studies in animals did not show any impairment of fer
that was attributable to the drug.
Pregnancy: Pregnancy Category C. INDERAL has been shown to be embryotoxil
animal studies at doses about 10 times greater than the maximum recommended hul
dose.
There are no adequate and well-controlled studies in pregnant women. INDERAL sm
be used during pregnancy only if the potential benefit justifies the potential risk to the fe
Nursing Mothers INDERAL is excreted in human milk Caution should be exercised w|
INDERAL is administered to a nursing woman.
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and t
rarely required the withdrawal of therapy.
Cardiovascular bradycardia; congestive heart failure; intensification of AV block; hi
tension; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usual!
the Raynaud type.
Central Nervous System. Lightheadedness; mental depression manifested by inson;
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; vij
disturbances; hallucinations; an acute reversible syndrome characterized by disorient:
for time and place, short-term memory loss, emotional lability, slightly clouded sensor;
and decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarr
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with ac;]
and sore throat, laryngospasm and respiratory distress.
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytop >
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has t;'
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male ir?r3
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reac t,
involving the skin, serous membranes and coniunctivae reported for a beta blocker (pH
tolol) have not been associated with propranolol. t ,.
REFERENCES.
1. Epstein FH, Rosa RM: Adrenergic control of serum potassium. N Engl J 1
1983;309:1450-1451. 2. Vincent HH, Boomsma F, Man in't Veld AJ, et al: Effects of sele 5
and nonselective (3-agonists on plasma potassium and norepinephrine. J Cardiovasc I £ ,
macol 1984;6 107-114 3. Struthers AD, Whitesmith R, Reid JL Prior thiazide diuretic tit
ment increases adrenaline-induced hypokalaemia. Lancet 1983,1 1358-1361 4. Browr ID-
Brown DC, Murphy MB Hypokalemia from beta?-receptor stimulation by circulating -
nephrine N Engl J Med 1983;309:1414-1419 5. Struthers AD, Reid JL, Whitesmith R,
Effect of intravenous adrenaline on electrocardiogram, blood pressure, and serum
tassium Br Heart J 1983:49 90-93. 6. Holland OB, Nixon JV, Kuhnert L: Diuretic-indi
ventricular ectopic activity Am J Med 1981,70:762-768
9410/ *
AYERST LABORATORIES
New York, N Y. 10017
Copyright © 1984 AYERST LABORATORIES
Division of AMERICAN HOME PRODUCTS CORPORATION
i
C3ITUARIES
rs. Bemardin; Camejo;
arr; Carr as; D’Agostin;
. inkel; Hely; Kratka;
acaulay; Mettler;
odarelli; Ortolano; Parvin;
ollis; and Sandella
\
It. R.M. Bemardin
A pediatrician with offices in Col-
1 gswood and Cherry Hill, Ronald
D|mrice Bemardin, M.D., died at his
Ime on July 19, 1984. Bom in Col-
nbia, South Carolina, in 1918, Dr.
Imardin’s family moved to Phila-
dphia. He received his medical
cgree from Jefferson Medical Col-
lie in 1944, and immediately
ftered the United States Army’s
iidical corps for the duration of
^Drld War II. A member of our
< imden County component and the
merican Medical Association, Dr.
1 Tnardin was board certified in his
: ecialty. For 20 years he was chief
< the pediatrics department at
boper Hospital/University Medical
bnter, and also was affiliated with
' ar Lady of Lourdes Hospital, Cam-
1 n, and Garden State Hospital,
arlton. Dr. Bemardin was clinical
ofessor of pediatrics at the Univer-
ty of Medicine and Dentistry’s
rmden campus.
Dr. Rafael Camejo
Word has been received of the
death of Rafael Camejo, M.D., on May
8, 1984. Bom in 1926 in the Domin-
ican Republic, Dr. Camejo earned
his medical degree at the University
of Santo Domingo in 1954. He com-
pleted his internship at St. Peter’s
Hospital, New York, in 1956. An
anesthesiologist, Dr. Camejo was af-
filiated with West Hudson Hospital,
Kearny; he was a member of our
Hudson County component.
Dr. Josephus C. Carr
At the age of 78, Josephus Cor-
nelius Carr, M.D., a member of our
Essex County component, died on
August 16, 1984. Dr. Carr was a gen-
eral surgeon who received his medi-
cal degree from Harvard University
College of Medicine in 1925. His of-
fice was located in Newark and Dr.
Carr was affiliated with both Doc-
tors Hospital and Beth Israel Medi-
cal Center in that same city. Dr. Carr
was a member of the American
Medical Association, and a Fellow of
the American Geriatric Society, of
the American Society of Abdominal
Surgeons, and of the International
Academy of Proctology. In 1975, in
recognition of his 50 years as a
physician. Dr. Carr was a recipient
of MSNJ’s Golden Merit Award.
Dr. Peter D. Carras
The former medical director of
Christian Health Care Center, Wyc-
koff, Peter Demosthenes Carras,
M.D., died on July 4, 1984. Bom in
1918 in Paterson, Dr. Carras earned
his medical degree at Hahnemann
Medical College and Hospital, Penn-
sylvania, in 1943. An internist in
private practice. Dr. Carras also was
affiliated with Paterson General
Hospital until 1975; from 1975 to
1983, Dr. Carras was affiliated with
the Christian Health Care Center. A
member of our Passaic County com-
ponent and of the American Medical
Association, Dr. Carras was a
Diplomate of the American Board of
Internal Medicine and a Fellow of
the American College of Physicians.
Dr. Henry D’Agostin
At the advanced age of 86, Heniy
D’Agostin, M.D., a gynecologist until
his retirement in 1962, died on July
5, 1984. Bom in Union City, Dr.
D’Agostin obtained his medical
degree from New York University
School of Medicine in 1923. He had
practiced his specialty in Cliffside
Park, and had been affiliated with
Englewood Hospital for 35 years. He
was a Fellow of the American College
of Obstetricians and Gynecologists,
and a Fellow of the American College
of Surgeons. Dr. D’Agostin had been
a member of our Bergen County
component and of the American
Medical Association.
Dr. JerroW S. Finkel
At the untimely age of 55, Jerrold
S. Finkel, M.D., an obstetrician and
gynecologist with offices in Edison,
died on August 25, 1984. A member
of our Middlesex County compo-
nent, Dr. Finkel was bom in Newark,
and was a graduate of Hahnemann
Medical College and Hospital, Penn-
sylvania in 1955. He was a member
of the American Medical Associa-
tion, board certified in his specialty,
and a Fellow of the American College
of Obstetricians and Gynecologists.
He had been an assistant clinical
professor at the New Jersey Medical
School, Newark, and Rutgers Medi-
cal School, Piscataway.
Dr. Charles J. Hely
Charles James Hely, M.D., a phy-
sician of Westfield who practiced his
specialties in that city for over 30
years, died at his home on August
14, 1984. Bom in 1914, Dr. Hely re-
ceived his medical degree from
Hahnemann Medical College and
Hospital, Pennsylvania, in 1943. He
had been an obstetrician and chair-
man of that specialty’s department
at both Muhlenberg and Rahway
Hospitals, as well as an assistant
clinical professor of obstetrics and
gynecology at both the New Jersey
Medical School, Newark, and Rutgers
Medical School, Piscataway. In more
recent years he switched to family
practice, and finally practiced oc-
cupational medicine, having served
till his death from 1975 as medical
director for E.I. duPont de Nemours
& Company at their facilities in
Linden and Newark. Dr. Hely was a
member of our Union County com-
ponent, a member of the American
Medical Association, and a Fellow of
the American College of Obstetri-
cians and Gynecologists. He had
)L. 81— NUMBER 11— NOVEMBER 1984
1005
been active in community affairs:
serving as school physician for the
Westfield school system for 35 years,
medical advisor to the Westfield
Rescue Squad, and a member of the
advisory council of the Visiting
Nurses Association. In 1973 he
served a tour of duty with Project
Hope on a Navajo reservation in Ari-
zona During World War II, Dr. Hely
served as a battalion surgeon with
the U.S. Marine Corps, and was
awarded the Bronze Star for bravery
in action.
Dr. Harold D. Kratka
Harold David Kratka M.D., a
member of our Morris County com-
ponent, died on July 5, 1984, at the
untimely age of 58. Bom in the
Bronx, Dr. Kratka received his medi-
cal degree from the Faculty of Medi-
cine, University of Geneva Switzer-
land in 1956. A pediatrician, he es-
tablished a practice in Dover and
had been the head of the pediatrics
department at Dover General Hospi-
tal. Dr. Kratka was board certified in
his specialty and was a Fellow of the
American Academy of Pediatrics.
Dr. Francis A. Macaulay
We just have learned of the death
on March 20, 1984, of Francis A.
Macaulay, M.D., in Delray Beach,
Florida A member of our Bergen
County component. Dr. Macaulay
was bom in Canada in 1898, and
received his medical degree from
McGill University Faculty of Medi-
cine, Montreal, Canada in 1926. An
obstetrician. Dr. Macaulay estab-
lished his practice in Teaneck where
he remained until his retirement in
1975. He was a member of the
American Medical Association. Dr.
Macaulay had been affiliated with
Holy Name Hospital, Teaneck, and
had served as school physician in
that community. In 1976, Dr.
Macaulay received MSNJ’s Golden
Merit Award honoring his 50 years
as a physician.
Dr. Fred A. Mettler
A member of our Morris County
component, Frederick Albert Met-
tler, M.D., died on May 22, 1984.
Bom in 1907 in New York, Dr. Met-
tler received his medical degree from
the University of Georgia Medical
School in 1937. A private practicing
specialist in neurology and psy-
chiatry, Dr. Mettler was a member of
the American Medical Association.
Dr. Mettler was active in Medical So-
ciety affairs; for ten years he served
on the Committee on Medical De-
fense and Insurance. He also served
as chairman of an advisory commit-
tee to review health care in New Jer-
sey prisons.
Dr. Walter H. Modarelli
Walter Hector Modarelli, M.D., at
the age of 74, died on May 27, 1984.
Dr. Modarelli, a retired member of
our Hudson County component, was
an internist affiliated with St. Mary
Hospital, Hoboken, and Poliak Hos-
pital, Jersey City. A Diplomate of the
American Board of Internal Medi-
cine, Dr. Modarelli also was a Fellow
of the American Academy of
Cerebral Palsy and a member of the
American Medical Association. Dr.
Modarelli received his medical
degree from the University of Penn-
sylvania School of Medicine in 1935.
Dr. James J. Ortolan©
A specialist in dermatology and
cancer diseases, James Joseph Or-
tolano, M.D., died on June 23, 1984.
Dr. Ortolano, a retired member of
our Hudson County component, was
bom in 1907 and graduated from
Georgetown University School of
Medicine in 1932. He completed an
internship at St. Maiy Hospital,
Hoboken, and then entered private
practice. During his affiliation with
St. Maiy Hospital, Dr. Ortolano
served as president of the hospital
medical staff. In 1982, Dr. Ortolano
received MSNJ’s Golden Merit
Award for 50 years of medical service
to his community.
Dr. Robert W. Parvin
On August 26, 1984, Robert W.
Parvin, M.D., tragically died by
drowning in the family swimming
pool, at the age of 64. Bom in
Camden, Dr. Parvin received his
medical degree from the UniversF
of Pennsylvania School of MediciT
in 1944. His prime specialty was o
thopedic surgeiy, and he was a
filiated with Burlington Counil
Memorial Hospital, Mount Holly, f,
a consultant for that specialty, an
also served as their director of med
cal education. Dr. Parvin was
member of our Burlington Couni
component, and also a member <
the American Medical Associatioi!
He was board certified in orthoped
surgeiy. For more than 30 years D
Parvin had served with the Unite
States Army’s Medical Corps; he ha
been chief of orthopedic surgery i
the U.S. Military Academy, We:
Point, New York, and had done torn
of duty in Europe, Korea and mil l
tary facilities in the United State
emerging with the rank of colonel i
1976.
Dr. Nicholas L. Pollis
We just have learned of the deat
on June 10, 1984, of Nicholas I
Pollis, M.D., a member of our Esse
County component. Bom in 1901
Dr. Pollis received his medics
degree from Tufts University Schoc
of Medicine in 1928, and prior to hi
retirement in the early 1970s, h
had practiced family medicine ii
Newark. He had been affiliated wit!
St. James Hospital and Sain
Michael’s Medical Center, Newarl
Dr. Pollis had been a member of th
American Medical Association.
Dr. Joseph F. Sandella
An internist in New Brunswicl
Joseph Frank Sandella, M.D., die
on August 28, 1984. A native of Ne^
York City, bom in 1905, Dr. Sandell
was graduated from Bellevue Hosp
tal Medical College in 1931. A merr
ber of our Middlesex County compc
nent. Dr. Sandella was boar
certified in his specialty, and a Fe
low of the American College of Ph}
sicians. He had been affiliated wit
St. Peter’s and Middlesex Genen
Hospitals, New Brunswick, and wit
Roosevelt Hospital, Metuchen. I
1981, Dr. Sandella received MSNJ
Golden Merit Award honoring his 5
years of medical practice.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
1006
Author Information
Style
Sheet
The Journal is the
official organ of the
Medical Society of New
Jersey. The goals of The
Journal are educational
and informational. All
material published in The
Journal is copyrighted by
MSNJ.
t CONTENT
The educational content of each
[issue appears as scientific articles,
rased on research, original concepts
relative to epidemiology of disease,
rnd treatment methodology; case re-
ports based on unusual clinical ex-
periences; review articles; clinical
Ihotes, succinct items on some
aspect or new observation or tech-
lique of a case experience; and
repecial articles, which include evalu-
ations, policy and position papers,
band reviews of nonscientific sub-
jects. Other topics include commen-
tary (critical narration); medical his-
rltory; therapeutic drug information;
pediatric briefs; nutrition update;
and an opinion column. Editorials
are prepared by the Editor and by
guest contributors on timely and rel-
evant subjects; editorials are the re-
sponsibility of the author. The Doc-
tors’ Notebook section contains or-
ganizational, informational, and ad-
ministrative items from MSNJ and
from the community. Letters to the
Editor and book reviews are Wel-
lcome and will be published as space
ipermits. The principal aim in the
preparation of a contribution
ishould be relevance to diagnosis and
treatment and to education of pa-
tients and professionals. Preference
will be given to professional authors
from New Jersey and to out-of-state
lecturers who submit a suitable
manuscript based on a presentation
made in New Jersey.
ASSIGNMENT OF COPYRIGHT
In compliance with the Copyright
Revision Act of 1976 (effective Janu-
ary 1, 1978), a transmittal letter or
a separate statment accompanying
material offered to The Journal of
the Medical Society of New Jersey
must contain the following language
and must be signed by all authors:
“In consideration of The Journal
of the Medical Society of New Jersey
taking action in reviewing and edit-
ing my submission, the author(s)
undersigned hereby transfers, as-
signs, or otherwise conveys all
copyright ownership to the Medical
Society of New Jersey, in the event
that such work is published in The
Journal, MSNJ.”
SPECIFICATIONS
Submit two manuscripts that
must be typewritten and double-
spaced on 8'/2" by 11" paper.
Statistical methods used in articles
should be identified. Acknowl-
edgements will be made only for
specific preparation of an essential
part of the manuscript.
Authors are asked to seek clarity,
accuracy, and originality; attention
to details of grammar, spelling, and
typing are important.
The title page should include the
full name, degrees, and affiliations of
all authors, and the name and ad-
dress of the author to whom reprint
requests should be sent.
The author should submit a 40-
word abstract to be used at the be-
ginning of the article.
Tables must be typewritten and
double-spaced on separate 8V2" by
11" sheets, with a title and number.
Symbols for units should be con-
fined to column headings, and ab-
breviations, properly explained,
should be kept to a minimum.
Illustrations should be pro-
fessional quality, black-and-white
glossy prints. The name of the
author, figure number, and the top
of the figure should be noted on a
label attached to the back of each
illustration. Where photographs of
patients are used, the subjects
should not be identifiable or publi-
cation permission, signed by the
subject or responsible person, must
be included with the photograph.
Material taken from other publi-
cations must give credit to the
source; written permission for re-
publication from the original pub-
lisher must be submitted. The cost
of color photographs must be borne
by the author.
Generic names should be used
with proprietary names indicated
parenthetically or as a footnote with
the first use of the generic name.
Proprietary names of devices should
be indicated by the registration sym-
bol— ®.
The summary of the article should
not exceed 250 words; it should con-
tain only essential facts.
References should not exceed 35
citations except in review articles,
and should be cited consecutively in
the text by numbers in parentheses
at the end of the sentence. The refer-
ence list should be typewritten and
double-spaced on separate 8V2" by
11" sheets in the numerical order in
which they are first cited in the text.
The style of reference is that of Index
Me die us:
1. Goldwyn RM: Subcutaneous
mastectomy. J Med Soc NJ
74:1050-1052, 1977.
2. Dixon WJ, Massey FJ: Introduc-
tion to Statistical Analysis. New
York, NY, McGraw-Hill, 1969, pp.
42-48.
PUBLICATION POLICY
Receipt of each manuscript will be
acknowledged and a copy delivered
to the Editor who refers the paper to
one or more members of the Edi-
torial Board. The final decision is re-
served for the Editor. No direct con-
tact between the reviewers and the
authors will be permitted, but
authors will be informed of the re-
viewers’ comments. The publication
lag for original articles may be six
months or more. Galley proofs will
be submitted to the author for cor-
rection of typographical errors.
REPRINT ORDERS
Reprints may be ordered after the
author is notified that the article
has been selected for a specific issue
of JMSNJ. A check for the cost of
reprints including remake charge if
order is received after due date must
accompany the order.
COMMUNICATIONS
All communications should be
sent to the Editor, The Journal,
MSNJ, 2 Princess Road, Law-
renceville, NJ 08648.
VOL. 81— NUMBER 11— NOVEMBER 1984
1007
Kirwan Financial Croup, Inc.
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THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
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Or call Susan L. Hughes, Physician
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PRACTICES
FOR SALE
Allergy-
Suburban Philadelphia. Very efficient practice
which offers considerable growth potential.
Pediatric-
Central New Jersey. High quality practice in
residential area.
Ob/Gyn—
Washington state. Physician is relocating. Must
sell.
Rheumatology/LM.—
Arizona
ENT-
Several large practices in Mid-Atlantic region.
For more information on these and other available
private practices, please call:
(215) 667-8630
Health Care Personnel Consulting, Inc.
403 GSB Building
One Belmont Avenue
Bala Cynwyd, Pa. 19004
VOL. 81— NUMBER 11— NOVEMBER 1984
1009
TAX ADVANTAGED
INVESTMENT
Available in Princeton, N.J. technology operation.
Already approved by the IRS, total commitment made
before the end of the year is deductible as expenses
against taxable income.
For more information call Mr. Duncan anytime at
201-842-9247 or leave word anytime at 1-800-824-7888
operator 314.
It’s A Major Medical Explosion
The Lakewood, Toms River and Point Pleasant hospitals
are all going ahead with major expansion programs . . .
Bricktown opens new facility.
Cross River Professional Center
400 to 2,300 Square Feet
Va Mile South of Kimball Medical Center
• $12 per square foot minutes to all four major
• Graduated rent schedules hospitals
• Ownership options available • Private entrances and all
• Fully landscaped services available
• Centrally located and 10 • Equipment leases available
BKRRy/WOR ENTcRPRIJEi
1200 River Avenue (Route 9), Lakewood, NJ 08701 • (201) 367-2226
I
Personnel
See Also
Page 1009
CARDIOLOGIST:
Opportunity to practice cardiology with well-estab-
lished practice conveniently located to a large teaching
hospital. Duties include supervising and interpreting
Treadmills, Holter monitors, 2D and M-Mode
Echocardiography performed in office, patient examin-
ations, hospital rounds and cardiac catheterizations.
Abilities to do streptokinase and/or angioplasty de-
sirable. Excellent beginning salary and fringe benefits.
Located in Pennsylvania.
Reply with C-V to Box No. 97, JMSNJ Immediate
Opening.
Family Practitioner
Excellent opportunity for Board Certified/Eligible
Family Practitioner to take over established Hos-
pital-Owned Clinic practice near medium-sized
Eastern Pennsylvania city serving a referral popu-
lation of 35,000.
Contact: Judith Kennedy
1 -(800) 441-0996 or (215) 896-5080
MEDICAL PRACTICE
SALES AND APPRAISALS
We specialize in the valuation and selling of
medical practices. If interested in buying or selling
a medical practice, contact our Brokerage
Division at:
Health Care Personnel Consulting, Inc.
403 GSB Building
1 Belmont Avenue
Bala Cynwyd, PA 19004
215-667-8630
Plastic Surgeon
Attractive opportunity for Board Eligible or Board
Certified Plastic Surgeon to join an established
Plastic Surgeon in private practice. Affiliation with
three hospitals in medium-sized Pennsylvania city
serving a referral population of 1 million.
Contact: Tina Carrigan
1-(800) 441-0996 or (215) 896-5080
1010
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
CLASSIFIED ADVERT ISEMENTS
AMILY PHYSICIAN— BE with over
iwenty years practice experience in the
netropolitan area Wishes to relocate to
irea truly in need of an idealistic and
fledicated physician whose only goal is a
I1 ense of professional fulfillment true ser-
ice. Must be in New Jersey. Write Box
Jo. 105, JMSNJ.
FAMILY PRACTICE— Board eligible,
\CLS certified, personable, American
graduate. Desires office/hospital work in
>ntral/Northem NJ. Please call 201-
145-7162 or write to 218 Chestnut St,
PA-6, Roselle Park, NJ 07204.
GENERAL SURGEON— Board eligible,
vishes to join another surgeon or group
n the area of Union County or adjoining
counties. If interested contact Dr. Bruno
(215-787-2152.
INTERNIST — Will complete residency
June, 1985. Ambitious, with excellent
oedside manner, desires Southern New
Jersey group. If interested, please contact
Dr. Krueger at 215-456-7890.
ORTHOPAEDIC SURGEON— American
graduate, trained at Downstate Medical
Center, NJ. Seeks solo, group or hospital
based position. Call 212-819-8706 dur-
ing business hours or write to Box No.
100, JMSNJ.
PHYSICIAN — Lifetime NJ resident seeks
position in pediatric group after comple-
tion of postgraduate training. Avail
able July 1985. Please contact Charles
Geneslaw, 8372 Loveridge Court, Rich-
mond, VA 23229.
PHYSICAL THERAPIST — NJ registered,
ivailable. Seeking cooperative work with
physician home/office. Prefers NJ sea-
shore. Write Box No. 106, JMSNJ.
RADIOLOGIST — Board certified in
radiology and Nuclear medicine. NJ
licensed. Teaching hospital affiliation,
desires supervision of Nuclear Medicine
with ultrasound & CT. Reply Box No.
107, JMSNJ.
NEEDED — CARDIOLOGIST/
INTERNIST — To join busy Cardiology
and Internal Medicine practice. Immedi-
ate or July ’85 availability. Edison, NJ.
Reply Box No. 108, JMSNJ.
NEEDED — CARDIOLOGIST/
INTERNIST — Cardiologist needed for
multi-specialty Internal Medicine group
in South Jersey area near Atlantic City.
Salary with eventual partnership. Excel-
lent benefit package. If interested please
send curriculum vitae to Box No. 102,
JMSNJ.
NEEDED— EMERGENCY PHYSICIAN—
For new urgent care center in west
Morris County. Excellent opportunity.
Reply Box No. 104, JMSNJ.
NEEDED — INTERNIST — To join active 3
man pediatric practice. Fully furnished
offices with lab and x-ray available. Excel-
lent opportunity. Call 201-584-9390.
NEEDED— PHYSICIANS— New pro-
fessional office center. Ideal location for
all specialties. X-ray and lab available.
Many extras. 201-584-9390.
NEEDED— PHYSICIANS— For success-
ful well know walk-in medical office
center. Central New Jersey. Full and part
time. Skilled and personable, American-
trained MDs. Send C.V. to E.V. McGinley,
M.D., 1005 N. Washington Avenue, Green
Brook, NJ 08812 or call 201-968-8900.
NEEDED— PSYCHIATRIST— Board
certified or eligible. Full time position.
Full service mental health organization.
$49,000 plus extras, full benefits. Scenic
Bucks County near Philadelphia Call
Ms. Cifelli 215-822-7510.
FOR SALE — Collins Cardio Pulmonary
Lung Analyzer. Modular-Stead Wells
Model #0300 with Collins Eagle I Com-
puter and Printer. Interested parties call
Monday to Friday 609-883-0500, Ext. 13.
FOR SALE— PRACTICE/HOME/
OFFICE — 47 year old Family Practice
with home and office on large piece of
property in attractive Bergen County
community. Phone 201-438-8895.
FOR SALE— HOME/OFFICE— Four
bedroom colonial with 800 square feet
office attached with 4 exam rooms, lab,
waiting room. Located in fastest growing
area in NJ Marlboro, Manalapan Town-
ship. Asking $154,500. Call 201-
946-2286.
FOR SALE— PRACTICE— Established
Primary Care Practice in Ocean County
area. X-ray equipment, EKG and cardiac
monitor. Write Box No. 103, JMSNJ.
FOR SALE — South Orange, Prospect
Street, comer property. Eight rooms.
Suitable for professional use. $129,000
by owner. Please phone 201-762-4558.
OFFICE FOR RENT OR SHARE— New
Brunswick-Highland Park area Fur-
nished, 700 square feet, ample parking,
close to the hospital. Rent for
$500/month plus utilities or Share for
$300/month including utilities. Call
201-846-1661 or 572-7553.
OFFICE SPACE — Available for rent in
medical office in Kenilworth, NJ. Write
Box No. 109, JMSNJ.
OFFICE SPACE — Union, 2nd floor above
internist, busy neighborhood on busline.
Excellent location for optometrist psy-
chiatrist, dentist or surgical subspecial-
ty. Call 201-686-6616 Dr. Worth.
FOR RENT — Professional office in West
New York. Comer location with parking
space, on Doctor’s row. Close to hospital
and public transportation. Call 201-
278-1000 or 201-947-4333.
1ATE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
i/ORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
umbers, hyphenated words. Count name and address as five words, telephone number as one word, and "Write Box No. 000,
/o JMSNJ" as six words. COPY DEADLINE: Fifth of preceding month.
Y)L. 81
NUMBER 11
NOVEMBER 1984
101 1
The Medical Society of New Jersey
and the Healthcare Information Network
Television Program Guide
September-May
Closed circuit television programs related to issues and concerns of physician members of MSNJ.
• PRESIDENT’S FORUM: hosted by Frank Y. Watson, M.D., President, MSNJ
• THE IMPAIRED PHYSICIAN: hosted by David I. Canavan, M.D., Director,
Impaired Physicians Program, MSNJ
• STATE OF THE ART: hosted by Howard D. Slobodien, M.D., Past President, MSNJ
Programs will be featured the first, second, and third Tuesday of each month at 1:00 p.m. There will b
an 800 number for viewer participation.
Presented solely through those New Jersey hospitals which are subscribers to the HIN closed circu
television network. A listing of participating hospitals is on the bottom of this page.
For additional information or comments, contact the Medical Society of New Jersey, Department of Specie
Projects, A. Ronald Rouse, Director.
President’s Forum
Frank Y. Watson, M.D., President of
the Medical Society of New Jersey,
will host this program with selected
members from the Board of Trustees
and appropriate Council and Commit-
tee Chairpersons who will present in-
formation discussed at the previous
Board meetings.
Air time for this program is financed
by the Medical Society of New Jersey.
Tuesday, October 2, 1984
Tuesday, November 6, 1984
Tuesday, December 4, 1984
Tuesday, January 1, 1985
Tuesday, February 5, 1985
Tuesday, March 5, 1985
Tuesday, April 2, 1985
Tuesday, May 7, 1985
The Impaired Physician
Air time for this program is financed
by the Health Care Insurance Ex-
change (HCIE) and the Princeton In-
surance Company (PIC).
Tuesday, September 11, 1984
“Acute Case of the
Impaired Physician”
Tuesday, October 9, 1984
“Rehabilitation Programs”
Tuesday, November 13, 1984
“Aftercare”
Tuesday, December 11, 1984
“The Family and The Disease”
Tuesday, January 8, 1985
“Support Groups"
Tuesday, February 12, 1985
“Problems of Re-Entry"
Tuesday, March 12, 1985
"Followup/Monitoring”
Tuesday, April 9, 1985
“Recidivism/Special Problems"
State of the Art
Air time for this program is finance
by the Medical Society of New Jerse
Tuesday, October 16, 1984
Professional Liability
James E. George, M.D., J.D.
and
Mr. Adam Wilczek
Tuesday, November 20, 1984
Continuing Medical Education
Paul Hirsch, M.D.,
Edwin Messey, M.D.
and
Robert Rigolosi, M.D.
Tuesday, December 18, 1984
MSNJ Legislative Activities
Mr. Joseph Katz
and
Mr. Clark Martin
The following programs will be at
nounced at a later date:
Tuesday, January 15, 1985
Tuesday, February 19, 1985
Tuesday, March 19, 1985
Tuesday, April 16, 1985
Tuesday, May 21, 1985
Participating Hospitals*: Beth Israel Hospital; Freehold Area Hospital; Memorial General Hospital; Mor
ristown Memorial Hospital; Northern Ocean Hospital System, Inc.; Pascack Valley Hospital; Saint Elizabett
Hospital; Saint Mary’s Hospital; Saint Peter’s Medical Center; and Underwood-Memorial Hospital.
Hospitals Declaring a Preliminary Interest: Atlantic City Medical Center; ACMC-Mainland Division; Bett)
Bacharach Rehab. Hospital; Bridgeton Hospital; Carrier Foundation; Clara Maass Medical Center; Com'
munity Memorial Hospital; Deborah Heart & Lung Center; Englewood Hospital Association; Hackensacl1
Medical Center; Holy Name Hospital; Hospital Center at Orange; John F. Kennedy Medical Ctr.; KMH/UMC
Stratford Division; Kessler Institute for Rehab.; Monmouth Medical Center; Muhlenberg Hospital; Newarl
Beth Israel Medical Ctr.; Newton Memorial Hospital; Riverside Hospital; Salem County Memorial Hospital
and Saint Clare’s Hospital; Saint Francis Medical Center; Warren Hospital; West Hudson Hospital; and Wes
Jersey Hospital-Northern Division.
‘Listing of hospitals may have changed since this printing.
CLIP & SAV
1012
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Journal
of the Medical
Society of
E. & W. BLANKSTEEN
E. & W. BLANKSTEEN AGENCY, INC.
ADMINISTRATORS
THE MEDICAL SOCIETY OF NEW JERSE
ENDORSED PLANS OF: ■ t ' -7
LONG-TERM INCOME PROTECTION PLAN
MAJOR MEDICAL
OVERHEAD EXPENSE
HOSPITAL-MONEY
6-POINT HIGH LIMIT ACCIDENT
TERM LIFE
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MON-GMOCIP PROGRAMS OF:
HOMEOWNER’S
OFFICE PACKAGE
LIFE
IRA
PENSION
75 Montgomeiy Street
Jersey City, N.J0 07201
(201) 333-4340 1(800) BLANK AG
You know they mean well. But you also need to know that many
malpractice insurers simply don’t have The St. Paul’s financial
stability. Assets over $5.3 billion. Expertise measured by more than
130 years in the insurance business. Commitment best exemplified
by nearly 50 years of providing insurance to the medical community.
More than 55,000 physicians, over 1,550 hospitals and hundreds
of thousands of other health care professionals already insure
with The St. Paul. They benefit from loss prevention programs
that work, claims service that is second to none and the peace of
mind that only St. Paul’s experienced staff and financial resources
can provide.
Call Tim Morse, senior marketing officer in The St. Paul's Medical Services
Division. His toll free phone number is 1-800-328-2189, extension 7642.
He’ll explain our approach and put you in touch with an independent
insurance agent who understands your needs.
WORRY-FREE INSURANCE FROM
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St. Paul Fire and Marine Insurance Company/§t. Paul Mercury Insurance Company/The St. Paul Insurance Company/Sl. Paul Guardian Insurance Company/The
St. Paul Insurance Company of Illinois. Property and Liability Affiliation of The St. Paul Companies Inc., Saint Paul, Minnesota 55102.
your jnowndent
Imumctg AGENT
The Journal
>f the Medical
Society of
New Jerse
DECEMBER 196
1084
Features
Membership Newsletter
Physician Legal Bulletin
Professional Liability Commentary
Editorial
Hospital Governing Boards
Contributions
Compulsive Gambling
Assemblyman Chuck Hardwick, Westfield
New Jersey Combats Compulsive Gambling
R.M. Klein, Trenton
Aortic and Mitral Valve Replacement: Part 2
P. Olivien, M.D., andJ. Kostis, M.D., New Brunswick
Dialysis for End-Stage Renal Disease
JA. Walker, M.D., R. Dodelson, M.D., R.P. Eisinger, M.D.,
New Brunswick
Pharmacological Basis of Therapeutics: Dopamine Receptors
R.E. Heikkila, Ph,D„ Piscataway
Doctors’ Notebook
Trustees’ Minutes: October 21, 1984
UMONJ Notes, Stanley S. Bergen, Jr., M.D.
MSNJ Auxiliary, Grace Gellman
Current Legislation
Retired Lives Reserve
New Members
Physicians Seeking Location in New Jersey
MSNJ Departments
1984-1985 Liaison Representatives
CME Calendar
Book Reviews
Obituaries
Index: Volume 81
Information for Authors
On The Cover: There is a need
for full state involvement to
help compulsive gamblers in
New Jersey, We feature two
articles on the subject, begin-
ning on page 1046. Cover by
Frank Cecala
1016
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
New studies uncover
the potassium effects of
beta-2 blockade
Clinical pharmacology data
from The New England Journal
of Medicine:
when normal young men are given
infusions of epinephrine at levels such
as those that circulate in patients with
myocardial infarction , their serum
potassium concentrations fall by about
0.8 [mmol] per liter. Hypokalemia is
prevented by selective beta-2
blockade."'
Evidence |
that al I bei
are not cit
Right from the star
in hypertension..
80 mg 120 mg 160 mg
Please see brief summary of
information
Ur> 1 1 long ag mo
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The appearance of these capsules
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nce-daily INDERAL LA
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Once-daily INDERAL LA (propranolol HCI)
avoids the risk of diuretic-induced ECG ab-
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tion, INDERAL LA preserves potassium
balance without additive agents or supple-
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therapy with broad cardiovascular benefits.
Once-daily INDERAL LA
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Simply start with 80 mg once daily. Dosage
may be increased to 1 20 mg to 1 60 mg once
daily as needed to achieve additional control.
Like conventional INDERAL tablets,
INDERAL LA should not be used in the
presence of congestive heart failure, sinus
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degree, and bronchial asthma
Once-daily
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(PROPRANOLOL HCI) L(CAPSULESG
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION , SEE PACKAGE CIRCULAR.)
INDERAL* LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA Is available as 80 mg, 120 mg. and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided dally dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product, INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be Involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers In the brain. Although total peripheral
resistance may increase initially, It readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and somewhat variable. INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients.
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced Increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction. Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic
pressure and systolic election period. The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onset of pain and
increased work capacity.
In dosages greater than required for beta blockade. INDERAL also exerts a qumidine-like
or anesthetic-like membrane action which affects the cardiac action potential. The signifi-
cance of the membrane action in the treatment of arrhythmias is uncertain.
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the pial vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital. For example, in patients with severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of A V block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance The
effectiveness ol propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock, 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE; Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS, INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therapy
prior to major surgery is controversial. It should be noted, however, that the impaired ability of
the heart to respond to reflex adrenergic stimuli may augment the risks ot general anesthe-
sia and surgical procedures.
1 1
Q
, 80 i
1AL U
mg
.. -
|
\J
120
160
mg
The appearance of these capsules I
is a registered trademark
of Ayerst Laboratories.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor oj;
receptor agonists and its effects can be reversed by administration of such agent;'
dobutamme or isoproterenol However, such patients may be sub|ect to protracted n
hypotension. Difficulty in starting and maintaining the heartbeat has also been reports
bst3 blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent tig
pearance of certain premonitory signs and symptoms (pulse rate and pressure chani )
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may bq
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyrr 9>
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of syn'
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid functioi
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases havi_
reported in which, after propranolol, the tachycardia was replaced by a severe bradjH
requiring a demand pacemaker In one case this resulted after an initial dose oftir
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with irrl
hepatic or renal function. INDERAL (propranolol HCI) is not indicated for the treatr
hypertensive emergencies
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Fa
should be told that INDERAL may interfere with the glaucoma screening test. Withdraw, q
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart d q
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such an
pine should be closely observed if INDERAL is administered The added catechol) j
blocking action may produce an excessive reduction of resting sympathetic nervous 'I
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, orortHa
hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animaji
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month stil
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sigu
drug-induced toxicity. There were no drug-related tumongenic effects at any of the c|j{
levels Reproductive studies in animals did not show any impairment of fertility thin
attributable to the drug
Pregnancy: Pregnancy Category C. INDERAL has been shown to be embryot;
animal studies at doses about 10 times greater than the maximum recommended humai u
There are no adequate and well-controlled studies in pregnant women. INDERAL iu
be used during pregnancy only if the potential benefit justifies the potential risk to thrlu
Nursing Mothers INDERAL is excreted in human milk. Caution should be exercise' K
INDERAL is administered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient an a
rarely required the withdrawal of therapy. ■
Cardiovascular: bradycardia; congestive heart failure; intensification of A V block p
II I
tension; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usuall1
Raynaud type
Central Nervous System lightheadedness; mental depression manifested by ins
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia,
disturbances, hallucinations; an acute reversible syndrome characterized by disorients
time and place, short-term memory loss, emotional lability, slightly clouded sensoriuib
decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, dill
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic pharyngitis and agranulocytosis, erythematous rash, fever combined with fl
and sore throat, laryngospasm and respiratory distress
Respiratory: bronchospasm
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocyti
purpura
Auto-Immune In extremely rare instances, systemic lupus erythematosus ha:
reported.
Miscellaneous . alopecia, LE-like reactions, psoriasiform rashes, dry eyes, mat
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous re.]
involving the skin, serous membranes and coniunctivae reported for a beta blocker (pn
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloril
sustained-release capsule for administration once daily. If patients are switched trom INI|
tablets to INDERAL LA capsules, care should be taken to assure that the desired ther,
effect is maintained INDERAL LA should not be considered a simple mg for mg substi
INDERAL INDERAL LA has different kinetics and produces lower blood levels. RetitraticlJ
be necessary especially to maintain effectiveness at the end of the 24-hour dosing irM
HYPERTENSION— Dosage must be individualized The usual initial dosage is fn
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage n I
increased to 120 mg once daily or higher until adequate blood pressure control is acne
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosagej
mg may be required The time needed for full hypertensive response to a given do:’
variable and may range from a few days to several weeks.
ANGINA PECTORIS — Dosage must be individualized Starting with 80 mg INDEF|L
once daily, dosage should be gradually increased at three to seven day intervals until 0|
response is obtained Although individual patients may respond at any dosage le>
average optimum dosage appears to be 160 mg once daily. In angina pectoris, the val'llt
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few S
(see WARNINGS)
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDEFrl
once daily. The usual effective dose range is 160-240 mg once daily The dosage nil
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response
obtained within four to six weeks after reaching the maximum dose, INDERAL LA L3|
should be discontinued It may be advisable to withdraw the drug gradually over a p6)J
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily. I
PEDIATRIC DOSAGE — At this time the data on the use of the drug in this age group !ti
limited to permit adequate directions for use.
REFERENCES
1. Epstein FH, Rosa RM: Adrenergic control of serum potassium. N Engl J Med'3
309 1450-1451 2. Holland OB. Nixon JV, Kuhnert L: Diuretic-induced ventricular ej‘
activity. Am J Med 1981;70:762-768 3. Holme I, Helgeland A, Hermann I, et al: Treatnj
mild hypertension with diuretics The importance of ECG abnormalities in the Oslo study
MRFIT, JAMA 1984;251:1298-1299.
941 f
AYERST LABORATORIES
New York, N Y. 10017
Copyright © 1984 AYERST LABORATORIES
Division of AMERICAN HOME PRODUCTS CORPORATION
Membership
Newsletter
HE MEDICAL SOCIETY OF NEW JERSEY
VOLUME 17
IE MEDICAL FAMILY
The Impaired Physicians Program, in conjunction
' th the Auxiliaries of the Medical Society of New Jer-
i Y and of the New Jersey Association of Osteopathic
hysicians and Surgeons, is planning a program on
lie medical family: its strengths and weakness, and
i suring its survival. The program will be held on Sun-
<y, March 24, 1985. For further information, please
ill, Linda Pleva, at (609) 896-1766.
/OMAL TESTING
The AMA supports the draft, “Principles for the
l ilization and Care of Vertebrate Animals Used in
'sting. Research, and Training.” The Association
s ited that adherence to the principles would ensure
I at laboratory animals are used and cared for properly
1 thout imposing unreasonable restrictions on the
i e of animals in biochemical research. (Letter of Sep-
inber 20, 1984, to the National Institutes of Health.)
! ‘ECIAL JOURNAL ISSUES
The Journal of the Medical Society of New Jersey has
! Printed the William Carlos Williams Commemorative
hue (September 1983), a celebration of this New Jer-
! y physician and poet.
The September 1984 issue of The Journal is a study
< the history of the healing art in this state. “300 Years
< Medicine in New Jersey” is a collection of essays
; tended to dispel erroneous myths about the health
; ofessionals of New Jersey.
Both issues are available from MSNJ, Two Princess
i >ad, Lawrenceville, NJ 08648, for $5.
1 IEOPERATIVE CHEST X-RAY
The AMA supported the draft report, “Preoperative
1 lest Radiology,” which concluded that the amount of
< nically significant information derived from such x-
! ys is insufficient to justify ordering them routinely,
le Association also stated that it virtually is impos-
Dle to set forth a summary list of all appropriate
indications for ordering chest x-rays. (Letter of Sep-
tember 20, 1984, to the Food and Drug Adminis-
tration.)
MALPRACTICE REINSURANCE ASSOCIATION
The legislatively created Malpractice Reinsurance
Association which was opposed by MSNJ is in
financial difficulty. During the period from 1975 to
1977, MSNJ argued that the proposal was not real
insurance, was faulty in design, and was inadequately
financed. The Commissioner of Insurance has rec-
ognized the existence of the deficit and at a recent
meeting with MSNJ and Medical Inter-Insurance Ex-
change officers he agreed to appoint a Blue Ribbon
Committee to advise him on a proper resolution.
The issue simply stated is whether all physicians or
only those insured at the time of loss by the Re-
insurance Association will be assessed the necessary
amounts. MSNJ and MIIENJ have maintained that
only physicians insured by the Reinsurance Associa-
tion are subject to assessment.
Please monitor MSNJ and MIIENJ publications for
further information.
PERTUSSIS VACCINE
Pertussis vaccine availability remains tenuous, par-
ticipants concurred at the Pertussis Strategy Con-
ference sponsored by the American Academy of Pedi-
atrics. Due to a plethora of product liability lawsuits,
a number of large U.S. pharmaceutical houses have
ceased manufacturing the vaccine. As a result, some
physicians are concerned about rising prices and
whether the supply of the vaccine will be adequate to
meet the need. Lederle Laboratories remains the sole
manufacturer in this country. Connaught, a Canadian
company, also manufactures the vaccine for U.S. dis-
tribution. AAP President Paul Wehrle, M.D., said that
the reported cases of pertussis totaled 1 .500 to 2,000
per year. Deaths attributable to pertussis range from
only 6 to 1 1 a year. Without vaccine, the incidence of
the disease could rise. In foreign countries where im-
munization rates have dropped, such as Sweden, the
>L. 81— NUMBER 12— DECEMBER 1984
1021
United Kingdom, and Japan, pertussis cases have
quickly increased. In the UK where only 50 percent of
the population is immunized, a major epidemic is pre-
dicted. If the manufacturers stop making the vaccine,
Dr. Wehrle said, the AAP would work with government,
industry, the AMA, and other groups to guarantee its
continuing availability.
AMBULATORY SURGICAL CENTERS
The Division of Medical Assistance and Health Ser-
vices has proposed a rule that will appear in the New
Jersey Register. The rule concerns requirements and
reimbursement for Ambulatory Surgical Centers
(ASC).
The purpose of an ASC is to provide surgical services
to Medicaid patients not requiring hospitalization.
The type of surgical procedures covered are those that
cannot be performed in a physician’s office, but could
safely be performed in an ASC.
In order for an ASC to participate as a provider in
the New Jersey Medicaid Program, the ASC must be
approved by Medicare (Title XVIII), licensed by the New
Jersey Department of Health, and have signed an
agreement with the Division.
The surgical procedures that may be performed by
an ASC are assigned to one of four existing payment
groups. Reimbursement is made at the rate that cor-
responds with the appropriate group.
The physician who performs the surgery can submit
the HCFA-1500 claim form and be reimbursed in ac-
cordance with Medicaid policies, procedures, and fee
schedules.
Please note this is only a summary of the proposal.
The text of the proposal provides more detail.
DRIVING UNDER THE INFLUENCE
For the first offense for drunken driving, there is a
fine of not less than $250 nor more than $400, and
a period of detainment of not less than 12 hours nor
more than 48 hours spent during two consecutive days
of not less than 6 hours each day and served as
prescribed by the program requirements of the Intox-
icated Driver Resource Centers. In the discretion of the
court, the term of imprisonment will be not more than
30 days and the driver shall forthwith forfeit his right
to operate a motor vehicle over the highways of this
state for a period of not less than six months nor more
than one year.
For a second violation, a person shall be subject to
a fine of not less than $500 nor more than $ 1 ,000 and
shall be ordered by the court to perform community
service for a period of 30 days, which shall be of such
form and on such terms as the court shall deem ap-
propriate under the circumstances and shall be
sentenced to imprisonment for a term of not less than
48 consecutive hours, which shall not be suspended
or served on probation, nor more than 90 days, and
shall forfeit his right to operate a motor vehicle over
the highways of this state for a period of two years
upon conviction, and, after the expiration of said
period, he may make application to the director of the
Division of Motor Vehicles for a license to operate a
motor vehicle, which application may be granted at the
discretion of the director.
For a third or subsequent violation, a person shall
be subject to a fine of $1,000 and shall be sentencn
to imprisonment for a term of not less than 180 day '
except that the court may lower such term for each dj:
not exceeding 90 days, served performing communi
service in such form and on such terms as the cou
shall deem appropriate under the circumstances ar
shall thereafter forfeit his right to operate a mot
vehicle over the highways of this state for 10 year
If the driving privilege of any person is under rev
cation or suspension for a violation of any provisic
of this Title at the time of any conviction for a violatic
of this section, the revocation or suspension perk
imposed shall commence as of the date of terminatic.
of the existing revocation or suspension period,
court that imposes a term of imprisonment under th
section may sentence the person so convicted to tl
county jail, to the workhouse of the county wherein tli
offense was committed, to an inpatient rehabilitatic
program or to an Intoxicated Driver Resource Cent
or other facility approved by the director of tl
Division of Motor Vehicles and the director of tl
Division of Alcoholism in the Department of Healt
provided that for a third or subsequent offense a pe
son shall not serve a term of imprisonment at an Into:
icated Driver Resource Center.
A person who has been convicted of a previous vi
lation of this section need not be charged as a secon
or subsequent offender in the complaint made again:
him in order to render him liable to the punishmer
imposed by this section on a second or subsequei
offender, but if the second offense occurs more that
ten years after the first offense the court shall treat tl
second conviction as a first offense for sentenciri
purposes and if a third offense occurs more than te
years after the second offense, the court shall treat tl
third conviction as a second offense for sentencin
purposes.
A person convicted under this section must satis i
the screening, evaluation, referral, and program n!
quirements of the Division of Motor Vehicles’ Bureaf
of Alcohol Countermeasures, and of the Intoxicate
Driver Resource Centers. The sentencing court sha
inform the person convicted that failure to satisfy sue
requirements shall result in a mandatory two-day ten
of imprisonment in a county jail and a driver licens:
revocation or suspension and continuation of rev(|
cation or suspension until such requirements are sa
isfied, unless stayed by court order. Upon sentencing
the court shall forward to the Bureau of Alcoh<
Countermeasures a copy of a person’s conviction rc
cord. A fee, not to exceed $40, shall be payable to th
Division of Motor Vehicles for the Bureau of Alcohi
Countermeasures’ screening and evaluation progran
Upon conviction of a violation of this section, th
court shall collect the New Jersey driver’s license c
licenses of the person so convicted and forward sue
license or licenses to the director of the Division (
Motor Vehicles. The person convicted shall be ir
formed orally and in writing. A person shall be require
to acknowledge receipt of that written notice in wriii
ing.
FTNI
‘The nicest thing about being imperfect is the jo
it brings to others.”
1022
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE1
mricana
it Farm Resort
HOUSING
APPLICATION
219TH ANNUAL MEETING
MEDICAL SOCIETY OF NEW JERSEY
THURSDAY, MAY 2, TO SUNDAY, MAY 5, 1985
: DLLOWING ARE ALL-INCLUSIVE PACKAGE PLANS BASED ON
D IED AMERICAN PLAN, INCLUDING DINNER AND BREAKFAST
L STARTING WITH DINNER ON THE DAY OF ARRIVAL, THE SAT-
dV NIGHT BANQUET, LIVE CABARET SHOWS EACH EVENING
FIRING A DIFFERENT SHOW EVERY NIGHT, STATE SALES TAX,
) iLL GRATUITIES COVERING BELLMEN FOR IN/OUT LUGGAGE
Ice, chambermaids, and all MEAL SERVICE AS OUTLINED:
J NIGHT PACKAGE
5 0 PER PERSON, SINGLE OCCUPANCY
4 0 PER PERSON, DOUBLE OCCUPANCY
0 0 PER CHILD SHARING A ROOM WITH PARENTS
II i-NIGHT PACKAGE
7 0 PER PERSON, SINGLE OCCUPANCY
10 PER PERSON, DOUBLE OCCUPANCY
0 PER CHILD SHARING A ROOM WITH PARENTS
\IIGHT PACKAGE
0 PER PERSON, SINGLE OCCUPANCY
10 PER PERSON, DOUBLE OCCUPANCY
0 PER CHILD SHARING A ROOM WITH PARENTS
• Forms received after April 1, 1985,
will be confirmed on an “if avail-
able” basis,
• Fill out only one form for each room
required.
• DEPOSIT OF $100 PER ROOM
MUST ACCOMPANY FORM TO
CONFIRM RESERVATIONS.
• Please make check payable to
HOST FARM. Major credit cards ac-
cepted at hotel, but not for deposit.
• Hotel confirmation is required for
check-in.
• Send form and deposit to:
Host Reservations
2300 Lincoln Highway East
Lancaster, PA 17602
717-299-5500
K TYPE OF ROOM REQUIRED:
□ SINGLE OCCUPANCY □ DOUBLE OCCUPANCY
□ WILL BE SHARING ROOM**
| hotel will not be responsible for assigning roommates. Unless roommate is stated, you will be
assigned a single occupancy accommodation.
loE PRINT OR TYPE THE FOLLOWING INFORMATION:
31 MATES:
NO. of CHILDREN:
CHILDREN’S AGES:
ESS-
E:
STATE:
ZIP:
K IF OFFICIAL
DELEGATE □
COUNTY:
’ML DATE
DAY
CHECK-IN: AFTER 4 PM
1.
RTURE DATF
DAY
CHECK-OUT: BY 12 NOON
IEDICAL SOCIETY OF NEW JERSEY— 21 9TH ANNUAL MEETING
#2220
OL. 81— NUMBER 12— DECEMBER 1984
1023
LOCATION MAP
Americana
Host Farm Resort
2300 Lincoln Highway East (Route 30), Lancaster, Pennsylvania 17602 (717) 299-5500
FROM NEW YORK
Take New Jersey Turnpike
South to Pa Turnpike Take Pf
Turnpike West to Interchange No.
21 . Travel South on U S Rte. 222
to U S. Route 30 Travel East on
U S Route 30, approximately 5
miles to Americana Host Farm
Resort
FROM PITTSBURGH
& POINTS WEST
Travel East on Pa. Turnpike to
Int 19 Go South on 1-283 for 30
miles into Route 30 East for 6
miles to Americana Host Farm
Resort
FROM PHILADELPHIA
Take Pa Turnpike West to Inter-
change No. 21 Travel South on
U S Rte 222 to U S Route 30
Travel East on U S Route 30, ap-
proximately 5 miles to Americana
Host Farm Resort
FROM BALTIMORE
& WASHINGTON
Go North on Interstate Route
83 to York, Pa Turn East on U S
Route 30 for 32 miles to Ameri-
cana Host Farm Resort.
BY AIR
Harrisburg International Airpor
(just 35 minutes from Host by lim
ousine or car) via TWA and U S
Air, and Lancaster Airport only
minutes away with daily flights vi<
U S Air
BY RAILROAD
Amtrak to Lancaster Station.
Taxi and Rent-a-Car Service
available
1024
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE’
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject
MSNJ
Position
Committee
Present Statu
S-70
Codey
To change requirements for
eligibility to be Commissioner of
Health
Active Opposition
Senate: IHW
In committee
S-lll
Bubba
To require a physician to present
surgical consent forms at the time
surgery is agreed upon
Active Opposition
Senate: LIP
In committee
S-243
Hagedom
To provide procedures for
involuntary civil commitment of
the mentally ill
Active Opposition
Senate: IHW
In committee
S-424
Dorsey
To provide for the abolishment of
certain state agencies for specific
periods of time and to create a
Joint Legislative Committee on
Regulatory Agencies
Active Support
Senate: SGF&IR&VA
In committee
S-607
Bassano
To require the padding of all metal
bars in school buses with energy-
absorbing materials to be included
in the State Board of Education’s
rules and regulations
Active Support
Senate: LPS&D
In committee
S-723
Brown
To require the State Department
of Health to prepare a booklet on
breast cancer and require
physicians to give a copy of the
booklet to breast cancer patients
Active Opposition
Senate: IHW
In committee
S-752
Hirkala
To provide that certain
information of hospitals and long-
term health care facility review
committees be considered
confidential
Active Support
Senate: IHW
In committee
S-754
Hirkala
To provide immunity from civil
liability to members of hospital
governing bodies in connection
with certain review actions taken
by them
Active Support
Senate: J
In committee
S-1067
Feldman
To establish and license two
categories of social workers
Active Opposition
Senate: IHW
In committee
S-1079
Dumont
Provides for a three-year statute of
limitations, except for fraud,
intentional concealment, or
nontherapeutic or diagnostic
purpose. Minors have until age 1 1
or any injury prior to age 8
Active Support
Senate: J
In committee
S-1112
Hurley
To establish a cap on the amount
of damages which may be awarded
for pain and suffering in certain
civil actions
Active Support
Senate: J
In committee
S-1135
Dalton
To eliminate certain sources of
windfall benefits in personal
injury and wrongful death actions
Active Support
Senate: J
In committee
ft
* L. 81— NUMBER 12— DECEMBER 1984
1025
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject
MSNJ
Position
Committee
Present Status
S-1140
Feldman
To impose certain requirements
on the plaintiff in a medical
malpractice proceeding
Active Support
Senate: J
In committee
S-1182
Saxton
To establish the Automobile
Insurance Medical Fee Schedule
Board
Active Opposition
Senate: LIP
In committee
S-1190
Feldman
To authorize a court to award
reasonable attorney’s fees to a
party who prevails against a
frivolous claim for relief in a civil
action
Active Support
Senate: J
In committee
S-1714
Bassano
Licenses podiatric x-ray
technicians and allows them to
take x-rays of the leg* and foot
area Their curriculum and
examination will be established
and conducted by the Radiologic
Technology Board of Examiners
(‘Note: Current law limits the
podiatrist to the “lower leg” and
foot.)
Active Opposition
Senate: LIP
Out of
committee,
amended;
2nd reading
S-1775
Orechlo
Allows chiropractors who are
licensed to practice by written
examination in any state and who
have completed 4,300 classroom
hours in a chiropractic school to
become licensed to practice by
virtue of a clinical examination
Active Opposition
Senate: LIP
Out of
Assembly;
2nd reading
S- 1 839
Dalton
Amends existing law to allow a
psychologist to supply evidence of
a need for guardianship of a minor
who is in the custody of the
Division of Mental Retardation
Active Opposition
Senate: IHW
In committee
S- 1 840
Cardinale
Exempts the private practice of
medicine from the certificate of
need law
Active Support
Senate: IHW
In committee
S- 1 846
Garibaldi
Provides that cancers caused by
exposure to heat, cold, radiation,
or a known carcinogen which
manifest themselves in active
police or firemen are assumed to
be accidental and work-related
disabilities
Active Opposition
Senate: SGF&IR&VA
In committee
A-115
Otlowski
To authorize optometrists to
prescribe a limited number of eye
medications
Active Opposition
Assembly: HERP
In committee
A-708
Hardwick
To create a temporary committee
to study Diagnosis Related Group
System used for setting hospital
rates and appropriate $45,000
Active Support
Assembly: CHHS
In committee
1026
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject
MSNJ
Position
Committee
Present Stati
A-926
Weldel
To create an Automobile
Insurance Fee Schedule Board in
the Department of Insurance to
adopt a reasonable fee schedule for
medical services arising from
passenger automobile accidents
Active Opposition
Assembly: BI
In committee
A-960
Miller
To permit individual patients or
insurers to appeal hospital bills in
cases of assignments under the
Diagnosis Related Groups
Active Support
Assembly: CHHS
In committee
A-963
Miller
To eliminate the Diagnosis Related
Groups methodology and replace it
with one to be devised by the
Department of Health in one year
Active Support
Assembly: CHHS
In committee
A- 1056
Muziani
To require attending physicians
and certified nurse midwives to
inform pregnant women of any
drugs expected to be used during
pregnancy and the possible effects
Active Opposition
Assembly: CHHS
Out of
committee:
2nd reading;
amended
A-1116
Patero
To permit licensed psychologists
to certify disability under
Temporary Disability Benefits Law
Active Opposition
Assembly: L
Out of
committee:
2nd reading;
amended
A- 1 1 59
Herman
To require licensed physicians or
chiropractors to notify the Board
of Medical Examiners if they
accept Medicare assignments
Active Opposition
Assembly: HERP
In committee
A-1471
Garvin
To require a physician to obtain,
in advance, the patient’s
authorization to perform a biopsy
or mastectomy
Active Opposition
Senate: IHW
Passed in
Senate
A-1541
Karcher
To provide for the licensing of
persons who practice hypnosis
and limit the practice, teaching, or
preparation of hypnosis tapes to
licensed practitioners
Active Opposition
Assembly: HERP
In committee
A- 1559
Garvin
Requires Dept, of Health and the
State Board of Medical Examiners
to prepare a booklet on all aspects
of the treatment of breast cancer.
Physicians are required to
distribute the book to appropriate
patients and to discuss it with
them.
Active Opposition
Assembly: CHHS
In committee
A- 1682
Muhler
Creates a seven-person Board
within the Department of Human
Services vested with the authority
to release or continue the
commitment of persons who were
found incapable of standing trial
or not guilty by reasons of
insanity. A Superior Court judge
currently makes these decisions
Active Opposition
Assembly: CHHS
In committee
L. 81— NUMBER 12— DECEMBER 1984
Legislative Update
Status of Legislation on Which MSNJ Has Taken an Active Position
Bill
Subject MSNJ Committee Present Status
Position
A- 1870
Garvin
Amends existing statutes to Active Support Assembly: Cl In committee
require either seat belts or
restraint systems for all children
under ten in a motor vehicle.
Current law applies to children
under age five
A- 1921
Miller
Establishes a 3-year statute of Active Support Assembly: JUD In committee
limitations in tort actions against
health care providers. Children
would have until age 1 1 to bring
action for injuries prior to age 8.
After age 8, they come under the 3-
year standard. Fraud,
concealment, and unintentional
foreign bodies “toll” the statute
A- 1922
Miller
Provides that within 60 days of Active Support Assembly: JUD In committee
filing a medical malpractice
complaint, the plaintiff must
supply an affidavit, by a qualified
expert that reasonable cause
exists to believe malpractice
occurred
A-2115
Otlowski
Permits optometrists to use Active Opposition Assembly: CHHS Out of
topical drugs for treatment and committee:
diagnostic purposes 2nd reading
AR-31
Herman
Requests the Commissioner of Active Support Assembly: CHHS In committee
Health to vigorously educate the
public, particularly young people,
about the dangers of cigarette
smoking
Senate Assembly
Committee Key Committee Key
IHW: Institutions, Health and Welfare BI: Banking and Insurance
J:
LIP:
LPS&D:
SGF&IR&VA:
Judiciary CHHS: Corrections, Health and Human Services
Labor, Industry and Professions Cl: Commerce and Industry
Law, Public Safety and Defense HERP: Higher Education and Regulated Professions
State Government, Federal & Interstate JUD: Judicial
Relations & Veterans Affairs L: Labor
1028
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSB
Consider the
causative organisms...
cefaclor
250-mg Pulvules t.i.d.
offers effectiveness against
the major causes of bacterial bronchitis
H. influenzae, H. influenzae, S. pneumoniae, S. pyogenes
(ampicillin-susceptible) (ampicillin-resistant)
i)f Summary Consult the package literature for prescribing
rmation
cations and Usage: Ceclor" (cefaclor, Lilly) is indicated in the
tment of the following infections when caused by susceptible
inns of the designated microorganisms
ower respiratory infections, including pneumonia caused by
tptococcus pneumoniae (Diplococcus pneumoniae), Haemoph-
mfluenzae, and S pyogenes (group A beta-hemolytic
ptococci)
Appropriate culture and susceptibility studies should be
'ormed to determine susceptibility of the causative organism
leclor
traindication: Ceclor is contraindicated in patients with known
,irgy to the cephalosporin group of antibiotics,
nines IN PENICILLIN-SENSITIVE PATIENTS, CEPHALO-
)RIN ANTIBIOTICS SHOULD BE ADMINISTERED CAUTIOUSLY
RE IS CLINICAL AND LABORATORY EVIDENCE OF PARTIAL
)SS-ALLERGENICITY OF THE PENICILLINS AND THE
mOSPORINS, AND THERE ARE INSTANCES IN WHICH
IENTS HAVE HAD REACTIONS, INCLUDING ANAPHYLAXIS,
BOTH DRUG CLASSES
mtibiotics, including Ceclor, should be administered cautiously
ny patient who has demonstrated some form of allergy,
icularly to drugs
’seudomembranous colitis has been reported with virtually all
ltd spectrum antibiotics (including macrolides, semisynthetic
icillins, and cephalosporins); therefore, it is important to
sider its diagnosis in patients who develop diarrhea in
ociation with the use of antibiotics. Such colitis may range in
Brity from mild to life-threatening
reatment with broad-spectrum antibiotics alters the normal
3 of the colon and may permit overgrowth of Clostridia. Studies
cate that a toxin produced by Clostridium difficile is one
Mary cause of antibiotic-associated colitis.
Md cases of pseudomembranous colitis usually respond to
) discontinuance alone In moderate to severe cases, manage
1
ment should include sigmoidoscopy, appropriate bacteriologic
studies, and fluid, electrolyte, and protein supplementation
When the colitis does not improve after the drug has been
discontinued, or when it is severe, oral vancomycin is the drug
of choice for antibiotic-associated pseudomembranous colitis
produced by C difficile Other causes of colitis should be
ruled out
Precautions. General Precautions - If an allergic reaction to
Ceclor ’ (cefaclor, Lilly) occurs, the drug should be discontinued,
and. if necessary, the patient should be treated with appropriate
agents, eg. pressor amines, antihistamines, or corticosteroids.
Prolonged use of Ceclor may result in the overgrowth of
nonsusceptible organisms Carefu* 1 observation of the patient is
essential If superinfection occurs during therapy, appropriate
measures should be taken
Positive direct Coombs' tests have been reported during treat-
ment with the cephalosporin antibiotics. In hematologic studies
or in transfusion cross-matching procedures when antiglobulin
tests are performed on the minor side or in Coombs' testing of
newborns whose mothers have received cephalosporin antibiotics
before parturition, it should be recognized that a positive
Coombs' test may be due to the drug
Ceclor should be administered with caution in the presence ot
markedly impaired renal function. Under such conditions, careful
clinical observation and laboratory studies should be made
because safe dosage may be lower than that usually recommended
As a result ot administration of Ceclor, a false-positive reaction
for glucose in the urine may occur. This has been observed with
Benedict's and Fehling's solutions and also with Clinitest"
tablets but not with Tes-Tape" (Glucose Enzymatic Test Strip.
USP, Lilly)
Broad-spectrum antibiotics should be prescribed with caution in
individuals with a history of gastrointestinal disease, particularly
colitis.
Usage in Pregnancy - Pregnancy Category B - Reproduction
studies have been performed in mice and rats at doses up to 12
times the human dose and in ferrets given three times the maximum
human dose and have revealed no evidence of impaired fertility
or harm to the fetus due to Ceclor' (cefaclor, Lilly) There are,
however, no adequate and well-controlled studies in pregnant
women Because animal reproduction studies are not always
predictive of human response, this drug should be used during
pregnancy only if clearly needed
Nursing Mothers - Small amounts of Ceclor have been detected
in mother s milk following administration of single 500-mg doses
Average levels were 0 18, 0.20, 0.21 , and 0. 1b mcg/ml at two,
three, four, and five hours respectively. Trace amounts were
detected at one hour The effect on nursing infants is not known
Caution should be exercised when Ceclor is* administered to a
nursing woman
Usage in Children - Safety and effectiveness of this product for
use in infants less than one month of age have not been established
Adverse Reactions: Adverse effects considered related to therapy
with Ceclor are uncommon and are listed below
Gastrointestinal symptoms occur in about 2.5 percent of
patients and include diarrhea (1 in 70).
Symptoms of pseudomembranous colitis may appear either
during or after antibiotic treatment Nausea and vomiting have
been reported rarely
Hypersensitivity reactions have been reported in about 1 5
ercent of patients and include morbiliform eruptions (1 in 100)
ruritus, urticaria, and positive Coombs' tests each occur in less
than 1 in 200 patients. Cases ot serum-sickness-likc reactions
(erythema multiforme or the above skin manifestations accompanied
by arthritis/arthralgia and, frequently, fever) have been reported
These reactions aie apparently due to hypersensitivity and have
usually occurred during or following a second course ot therapy
with Ceclor Such reactions have been reported more frequently
in children than in adults. Signs and symptoms usually occur a lew
days after initiation of therapy and subside within a few days
alter cessation ol therapy No senmis sequelae have been reported
Antihistamines and corticosteroids appear to enhanco resolution
of the syndrome
Cases of anaphylaxis have been reported, hall ot which have
occurred in patients with a history of penicillin allergy
Other effects considered related to therapy included
eosinophilia (1 in 50 patients) and genital pruritus or vaginitis
(less than 1 in 100 patients)
Causal Relationship Uncertain - Transitory abnormalities in
clinical laboratory test results have been reported Although they
were of uncertain etiology, they are listed below to serve as
alerting information for the physician
Hepatic - Slight elevations in SGOT. SGPT. or alkaline
phosphatase values (1 in 40)
Hematopoietic - Transient fluctuations in leukocyte count,
predominantly lymphocytosis occurring in infants and young
children (1 In 40)
Renal - Slight elevations in BUN or serum creatinine (less than
1 in 500) or abnormal urinalysis (less than 1 in 200)
I061782R)
Note Ceclor* (cefaclor, Lilly) is contraindicated in patients
with known allergy to the cephalosporins and should be given
cautiously to penicillin-allergic patients
Penicillin Is the usual drug of choice in the treatment and
prevention of streptococcal Infections, including the prophylaxis
ol rheumatic fever See prescribing information
© 1984. ELI LILLY AND COMPANY
Additional information available to
the profession on request from
Eli Lilly and Company
Indianapolis Indiana 4628b
Eli Lilly Iftdntrits lw
Carolina Puerto Rico 00630
VOL. 81— NUMBER 12— DECEMBER 1984
1029
Angina
Protection
with Benefits for
a Lifetime
ONCE-DAILY CONTROL
WITH HEART-SAVING BENEFITS
By reducing heart rate and cardiac contractility, 1NDERAL LA helps
protect the heart from the potentially serious and debilitating
consequences of ischemia. A highly effective antianginal agent for
around-the-clock control of symptoms, INDERAL LA also provides
cardiovascular protection for a sense of security in the years ahead.
PROTECTION AND EXPERIENCE
NO CALCIUM BLOCKER CAN MATCH
Unlike calcium blockers, INDERAL LA — either alone or with a
nitrate — is recommended for early treatment of angina in the
majority of patients. Equally important, INDERAL LA delivers the
proven performance and safety profile of INDERAL tablets —
confirmed by millions of patients during 16 years of clinical use.
START WITH 80 MG ONCE DAILY
Dosage may be increased to 160 mg once daily, as needed, to
achieve optimal control. INDERAL LA should not be used in congestive
heart failure, sinus bradycardia, cardiogenic shock, heart block greater
than first degree, and bronchial asthma. Please see next page for
further details and brief summary of prescribing information.
ONCE-DAILY
ii
80 120
LONG ACTING mg mg
CAPSULES .
The appearance ol
INDFRAl LA
capsules is a register*1
trademark ol
Ayerst l ahoralones
Ayerst
ONCE- DAILY
JUST ONCE EACH DAY
FOR SIMPLIFIED CORE
THERAPY IN ANGINA (PROPRANOLOL HCI)
INDERAL LA ill
LONG ACTING
CAPSULES
80
mg
120
mg
160
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR )
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA Is formulated to provide a sustained release of propranolol
hydrochloride. Inderal LA is available as 80 mg, 120 mg, and 160 mg capsules.
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity. It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours. When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets. The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect. INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product. INDERAL LA
can provide effective beta blockade for a 24-hour period
The mechanism of the antihypertensive effect of INDERAL has not been established
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use. Effects on plasma volume appear to be minor and somewhat variable INDERAL has
been shown to cause a small increase in serum potassium concentration when used in the
treatment of hypertensive patients
In angina pectoris, propranolol generally reduces the oxygen requirement of the heart at
any given level of effort by blocking the catecholamine-induced increases in the heart rate,
systolic blood pressure, and the velocity and extent of myocardial contraction Propranolol
may increase oxygen requirements by increasing left ventricular fiber length, end diastolic i':
pressure and systolic election period The net physiologic effect of beta-adrenergic blockade
is usually advantageous and is manifested during exercise by delayed onsef of pain and
increased work capacity.
In dosages greater than required for beta blockade. INDERAL also exerts a quinidine-like
or anesthetic-like membrane action which affects the cardiac acLor: potentia The signifi-
cance ol the membrane action in the treatment of arrhythmias is uncertain
The mechanism of the antimigraine effect of propranolol has not been established Beta-
adrenergic receptors have been demonstrated in the plat vessels of the brain.
Beta receptor blockade can be useful in conditions in which, because of pathologic or
functional changes, sympathetic activity is detrimental to the patient But there are also
situations in which sympathetic stimulation is vital For^examplerTri patients with Severely"
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved. In the presence of A V block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable.
(INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope. INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therj
prior to ma|or surgery is controversial It should be noted, however, that the impaired abilil
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthr
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor of b
receptor agonists and its effects can be reversed by administration of such agents, e
dobutamine or isoproterenol. However, such patients may be subject to protracted se\
hypotension. Difficulty in starting and maintaining the heartbeat has also been reported
bets blockers
, DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the
pearance of certain premonitory signs and symptoms (pulse rate and pressure changes
acute hypoglycemia in labile insulin-dependent diabetes In these patients, it may be rr'
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroidi
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptc
of hyperthyroidism, including thyroid storm. Propranolol does not distort thyroid function te
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bi
reported in which, after propranolol, the tachycardia was replaced by a severe bradycai
requiring a demand pacemaker In one case this resulted after an initial dose of 5
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients with impai
hepatic or renal function INDERAL is not indicated for the treatment of hypertens
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Patie
should be told that INDERAL may interfere with the glaucoma screening test Withdrawal n
lead to a return of increased intraocular pressure
Clinical Laboratory Tests; Elevated blood urea levels in patients with severe heart disea
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re
pine should be closely observed if INDERAL is administered. The added catecholami
blocking action may produce an excessive reduction of resting sympathetic nervous actr
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orthost.
hypotension.
Carcinogenesis, Mutagenesis, Impairment of Fertility . Long-term studies in animals h,
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studie
both rats and mice, employing doses up to 150mg/kg/day, there was no evidence of sigmfic
drug-induced toxicity There were no drug-related tumorigenic effects at any of the dose
levels Reproductive studies in animals did not show any impairment of fertility that v
attributable to the drug.
Pregnant y Pregnancy Category C INDERAL has been shown to be embryotoxic
animal studies at doses about 10 times greater than the maximum recommended human do
There are nb adequate and well-controlled studies in pregnant women INDERAL sho
be used during pregnancy only if the potential benefit justifies the potential risk to the fet
Nursing Mothers: INDERAL is excreted in human milk Caution should be exercised wf
INDERAL is administered to a nursing woman
Pediatric Use: Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and h
rarely . requiredllhe withdrawal of therapy,
Cardiovascular: bradycarciia. congestive heart fajiure, intensification of A V block; hyj
tension: paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usually of
Raynaud type
Central Nervous System lightheadedness; mental depression manifested by insomr
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; vis
disturbances, hallucinations; an acute reversible syndrome characterized by disorientation
time and place, short-term memory loss, emotional lability, slightly clouded sensorium
decreased performance on neuropsychometrics
Gastrointestinal: nausea, vomiting, epigastric distress, abdominal cramping, diarrhi
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with achi
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm.
Hematologic: agranulocytosis, nonthrombocytopenic purpura, thrombocytopei
purpura.
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has be
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male imp
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reactic
involving the skin, serous membranes and coniunctivae reported fora beta blocker (practol
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride n
sustained-release capsule for administration once daily If patients are switched from INDER.
tablets to INDERAL LA capsules, care should be taken to assure that the desired therapeu
effect is maintained INDERAL LA should not be considered a simple mg for mg substitute
INDERAL. INDERAL LA has different kinetics and produces lower blood levels. Retitration m
be necessary especially to maintain effectiveness at the end of the 24-hour dosing interv
HYPERTENSION — Dosage must be individualized The usual initial dosage is 80 r
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage may
increased to 120 mg once daily or higher until adequate blood-pressure control is achieve
The usual maintenance dosage is 120 to 160 mg once daily In some instances a dosage of 6
mg may be required The time needed for full hypertensive response to a given dosage
variable and may range from a few days to several weeks
ANGINA PECTORIS — Dosage must be individualized Starting with 80 mg INDERAL
once daily, dosage should be gradually increased at three to seven day intervals until optimt
response is obtained Although individual patients may respond at any dosage level, t
average optimum dosage appears to be 160 mg once daily In angina pectoris, the value a
safety of dosage exceeding 320 mg per day have not been established
It treatment is to be discontinued, reduce dosage gradually over a period of a few weei
(see WARNINGS)
MIGRAINE — Dosage must be individualized. The initial oral dose is 80 mg INDERAL
once daily. The usual effective dose range is 160-240 mg once daily The dosage may
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory response is r|
obtained within four to six weeks after reaching the maximum dose, INDERAL LA thera
should be discontinued It may be advisable to withdraw the drug gradually over a period
several weeks
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily.
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group are I
limited to permit adequate directions for use.
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Laboratory
8833/3!
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
1032
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
:he medical society of new JERSEY VOLUME 5
rHE Alternative Medical Liability Act:
Proposed Solution to the Malpractice Problem
James E. George, m.d., j.d., and Madelyn S. Quattrone, j.d., lawrenceville
Physicians and their professional
liability insurers have been
proponents of reform in the area
medical malpractice litigation. In its present form,
edical malpractice litigation is expensive and time
)nsuming for everyone involved. Over recent years,
mrts have recognized new causes of action and have
warded monetary damages for new categories of in-
Eiries. In addition, court backlog results in lengthy
elays before cases, which have not been resolved out
f court, finally are adjudicated.
In April 1984, a federal bill, known as HR 5400, was
itended to reform some aspects of medical malprac-
ce litigation, and was introduced in the U.S. House
f Representatives. The bill has received mixed reviews
. om those likely to be affected by it.
This essay outlines the salient points of HR 5400
nd presents discussion of its potential impact on
hysicians, hospitals, insurers, patients, and at-
imeys.
According to its sponsors, W. Henson Moore (Re-
ublican, Louisiana) and Richard A. Gephardt (Demo-
rat Missouri), the bill is intended to provide an incen-
ve for hospitals, physicians, and other health care
roviders to identify and settle potential cases of
lalpractice. (In May, Senator David Durenberger
Republican, Missouri], introduced the same legis-
ition in the Senate as S 2690). The bill is intended
3 save insurance dollars by avoiding excessive re-
overies while assuring that patients are compensated
3r losses. The authors of the legislation hope that the
measure indirectly will minimize the need for the prac-
tice of defensive medicine and its resultant increase
a the cost of health care.
THE ALTERNATIVE MEDICAL LIABILITY ACT
If enacted, HR 5400, “The Alternative Medical Lia-
bility Act,” would provide a system for compensating
patients in cases of personal injury arising out of pa-
tient care provided under federally funded programs
(Medicare, Medicaid, CHAMPUS, CHAMPVA, and
others). The federal system would allow physicians and
other health care providers to avoid the risk of poten-
tial lawsuits for medical malpractice by enabling the
potentially liable health care providers to make an
offer, within a specified period of time, to pay the in-
jured patient’s economic losses. The patient to whom
an offer is made would lose his right to sue for dam-
ages in a court of law.
The offer is a commitment to pay compensation ben-
efits and not a specified amount of dollars. Under the
proposed legislation, the injured patient would be enti-
tled to receive compensation for certain economic
losses and attorney fees, but could not recover monies
for pain and suffering and loss of consortium claims.
The alternative federal system would not apply to
cases involving the death of a patient or intentional
misconduct by a health care provider. Nor would it
apply to any personal injuries occurring before Janu-
ary 1987, or to malpractice cases in those states that
have enacted liability systems which conform to the
federal alternative system.
The proposed federal system of patient compensa-
*From the Department of Professional Liability Control.
MSNJ, where Dr. George is Director and Editor of PLB and
Ms. Quattrone is Assistant Editor of PLB. Correspondence
may be addressed to A Ronald Rouse. MSNJ, Two Princess
Road, Lawrenceville, NJ 08648.
/OL. 81— NUMBER 12— DECEMBER 1984
1033
tion would be applicable only to cases arising out of
medical services rendered under Medicare, Medicaid,
the CHAMPUS and CHAMPVA programs, the federal
program employees health benefits program, and other
federal health programs.
HR 5400 has received mixed
reviews from those likely to
be effected by it.
TIMELINESS
The bill gives hospitals and doctors a specified
period of time to look over their adverse outcome cases
to determine which ones are probable liability cases
and to identify which cases are likely to lead to liti-
gation. The health care providers are expected to iden-
tify the cases for which they will make a compensation
offer, or “tender of compensation benefits” as it is
termed in the proposed bill.
Physicians and other health care providers must re-
view their cases expeditiously. Tenders must be made
to injured patients no later than 180 days after the
date of the patient’s discharge from the institution
where the occurrence took place or, if the patient was
not an inpatient, 180 days after the date of the incident
giving rise to the injury.
Compensation benefits must be paid no later than
30 days after the date that the claimant has provided
reasonable proof of the fact and amount of net eco-
nomic loss incurred. In the event benefits are not paid
on a timely basis, claimants are entitled to interest at
the annual rate of interest applied to judgments in the
state where the injury occurred.
JOINT LIABILITY
The proposal permits physicians and other health
care providers who make an offer of payment to a
patient to join as parties other physicians or health
care providers. The party who is joined is deemed to
have agreed to pay a share of the compensation ben-
efits. Disagreements between the parties with regard
to any party’s share will be resolved by binding arbi-
tration based on the comparative fault of the providers.
COMPENSATION BENEFITS
The proposed bill restricts the monetary recovery
allowable to injured patients. The injured patient will
have no right to recover monetary damages for pain
and suffering, mental anguish, physical impairment,
punitive damages, lost earning capacity, or loss of con-
sortium. A patient to whom a tender is made is limited
to recovery for his net economic loss plus attorney’s
fees. Economic loss includes reasonable expenses in-
curred for products, services, and accommodations
reasonably needed for medical care, training, and re-
medial treatment, including rehabilitation treatment
and occupational training. A patient also may recover
for the loss of income from the work he would have
performed if he had not been injured. This amount,
however, will be reduced by any income from
substitute work actually performed by the individ i
or by income he would have earned in appropri e
available substitute work which he unreasonav
failed to undertake. Also, compensable are reasona e
expenses injured parties incur in obtaining ordin y
and necessary services they no longer are able to p -
form.
A significant feature is the requirement that all b i
efits payable by the provider must be reduced by e
amount payable by health, accident insurance, wagt r
salary continuation plan, or disability income or i
surance. Compensation benefits will cease after a fi »-
year period during which no claim for payments
made.
If it is determined that a provider has defemd
against a claim that is fraudulent or without a reas t
able foundation, the provider will be allowed to reco ?
reasonable attorney’s fees. Claimants also are entit e
to reasonable attorney’s fees.
COURT INVOLVEMENT
The federal proposal does not eliminate involvemt t
of the courts. Courts will not have a role in determin: g
liability under the proposal. Rather, courts will hav a
role in determining the adequacy of settlements a i
in the discovery of relevant information upon whji
the settlement amount is determined. Discov v
procedures such as depositions and interrogators
may be used in accordance with the rules of con.
Claimants would be obliged to disclose evidence f
their earnings and to submit to a physical or mer il
examination by a physician. In addition, a claim; t
must furnish reports relating to subsequent treatm< t
and testing in connection with his alleged injuric
Where compensation benefits have been offered y
a provider and the injured individual disputes e
amount of compensation owing, the provider or e
claimant may apply to a court of appropriate jurist
tion for a declaration as to the amount owed, /y
compensation benefit exceeding a value of $5,0004
net economic loss must have the proposal of a co t
having jurisdiction of the matter. Court approval s
required to determine whether the settlement is a -
quate and fair to the claimant.
Payments may be made to a claimant in a lump sn
or in periodic payments. Settlement agreements r
judgments may be modified as to the amounts payc e
in the future under two circumstances. Payments n y
be adjusted upon a finding that a material ii
substantial change of circumstances in the claimai s
condition, loss, or rehabilitation has occurred after e
date of the agreement or judgment or where r v
evidence is discovered.
ASSIGNED CLAIMS PLAN
To participate in the federal plan, providers m it
participate, either directly or indirectly through an ji-
surance company, in an assigned claims plan, '.t
assigned claims plan may be organized by the st;p.
provided it meets federal requirements, or if no st e
plan exists, the assigned claims plan will be organ! d
federally and maintained. The purpose of an assigi d
claims plan is to provide for assessment of costs n
a fair basis. If a compensation obliger is financi y
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS '
1034
nable to pay compensation benefits it owes, the
aims will be assigned to a member or members of the
an.
OMMENTARY
Is the bill workable and is it fair? These are two
aestions invariably raised by health care providers
id their insurers. Attorneys invariably ask, is the bill
S institutional? Is it fair to provide a system of limited
covery for patient injuries to one segment of the
ipulation and a system for more expanded recovery
i another segment of the population?
Physicians and their insurers have applauded the
incept of the reduction in compensable categories of
images. The elimination of awards for pain and suf-
ring and for loss of consortium and the reduction in
rnefits by payments made to the patient by his in-
lrance or other collateral sources clearly are
meficial to the provider.
Other features of the bill have raised some cause for
incem. Will more patients be compensated under the
:|
I
proposed system as compared to the present system
so as to offset any benefits to physicians and their
insurers? Will the provisions for joining other phy-
sicians and providers result in the continued practice
of defensive medicine?
Physicians who believe they have provided proper
and acceptable care in cases which nonetheless result
in a bad outcome may be unwilling to make an offer
to pay compensation within the time period provided.
Is the short time period fair? Who will be empowered
to make a compensation offer, the physician or his
insurer? How will the assigned claims plan work?
On balance, it appears that HR 5400 seeks to ac-
complish many of the objectives sought by physicians
and their insurers. The bill deserves careful thought
and analysis so that the medical community can assist
drafters of the proposal.
There has never been a panacea in the area of medi-
cal malpractice. It is doubtful that HR 5400 will fill this
role. If HR 5400 is ever passed into law, it still will take
many months to know whether the medical malprac-
tice problem is better, worse, or the same.
1
I
0L. 81— NUMBER 12— DECEMBER 1984
1035
Find your doctor is the headline in what has to be one of the largest
posters ever produced — three feet by five.
This poster is in fact a directory of the approximately 10,000 Participating
- P.A.C.E. Physicians and Providers.
Distributed to 10,000 of our larger P.A.C.E subscriber businesses, it has
proven to be a unique and effective way to promote participation, and the
key role the Participating Doctor plays in this comprehensive health
care coverage.
Currently seven out of ten of your colleagues are participating
in P.A.C.E.
The P.A.C.E program takes into account
the kind of medicine you practice, and where
P.A.C.E. provides Participating Physicians
more equitable and consistant payments.
We actively seek your participation
in this unique P.A.C.E. program, Ip
for more information please call jm:
(201) 456-3200. ■
tOFESSIONAL LIABILITY
IMMENTARY*
[alpractice Rates
idAwards
■HHM
■orporate Negligence; Can Legislators
olve Problems?; Did You Know?; Award
m Deaf Child
I
I
n the recent Washington State
Supreme Court case of Pedroza
v Bryant 677 P.2d 166 (1984),
t! Court held that a hospital’s duty of care under the
Ttrine of corporate negligence extends only to those
ko are patients within the institution. Under the
Urine of corporate negligence, a hospital has the
nponsibility of supervising the medical treatment
p vided to hospital patients by members of the medi-
l staff. Hospital liability for the negligent acts of
p fsicians may arise when it is shown that a hospital
b i failed to exercise reasonable care in the granting,
Ijiewal, or delineation of privileges.
n the Pedroza case, a woman sought treatment at
b ' physician’s private office when she began to ex-
p ience problems associated with her pregnancy. The
man subsequently was admitted to Skagit Valley
spital where the child successfully was delivered by
arean section, though the patient did not survive,
e doctor who initially misdiagnosed her condition
1 limited staff privileges at the hospital,
he plaintiff had argued that the hospital should be
)le for the negligence of the physician because the
eased woman had chosen his services as a result
lis having staff privileges at the hospital and there-
e she was a potential patient of the hospital. The
irt rejected this argument, holding that: ‘The hospi-
I holds itself out to the community as a competent
I wider of medical care. The hospital does not hold
fL. 81— NUMBER 12— DECEMBER 1984
itself out as an inspector or insurer of the private
practices of its staff members. The delineation of staff
privileges by the hospital can only affect the
procedures used by staff members while they are in-
side hospital walls. The public cannot reasonably ex-
pect anything more.”
Although the Washington Court did not find liability
in this instance, the Pedroza case signifies the con-
tinuing trend of this country toward acceptance of the
doctrine of corporate negligence in medical malprac-
tice cases, a view which was accepted by a trial court
in this state in 1975 [Corleto v Shore Memorial Hospi-
tal, 138 N.J. Super 302 (Law Div. 1975)] and which is
likely to be accepted by the Supreme Court of New
Jersey should the issue be raised in that Court. At the
same time, the Pedroza case is significant because it
limits the doctrine to acts occurring in the hospital.
CAN LEGISLATORS SOLVE YOUR PROBLEMS?
“Stop harping about plaintiffs’ lawyers and banging
on legislative doors asking for special interest tort re-
form and instead get your own act together,” California
Assembly Speaker Willie Brown told the Physician In-
surers Association of America
Brown, who reportedly earned at least $ 1 30,000 from
his law practice and speeches last year to supplement
his $41,000 Assembly income, was described in News-
week (June 11, 1984) as an “ayatollah" who has be-
come the top Democrat in California and one of the
most influential blacks in American politics.
The major effect of his June 1 speech at Lake Tahoe
was to rankle members in what became a prolonged
sparring match between Brown and the audience.
Here’s a sampling of the pull-no-punches encounter:
Question: “I’m having trouble understanding how a
plaintiffs lawyer can justify receiving a $400,000 fee
in a million dollar malpractice verdict.”
Brown : “You folks have got to stop concentrating on
what a plaintiffs lawyer makes. Instances of those
large sums are rare. It’s like talking about what a doc-
tor charges. Your arguing that point is counter-
productive.”
Question : “Physicians are practicing defensive medi-
cine to reduce chances of being sued by patients, and
isn’t that bringing higher medical bills to patients who
are your constituents?”
Brown : ’That’s also a counterproductive argument.
When I need treatment, I want you to use every exotic
machine, every alternative method to make sure
nothing is missed so that I can be healthy forever and
ever and ever, without you being motivated by fear of
suit.”
Question: “Yet here is this plaintiffs lawyer with his
huge fee and in my (medical) practice there are limits
to what I can charge— limits from Medicare, Medicaid,
and state agencies."
Brown: “Again, you are making the wrong argument
in the wrong arena Lawyers’ fees are limited, too. in
many areas by various agencies when they represent
estates or minors or the indigent, and, oi course, you
are not required to take Medicare patients."
•This item from the Department of Professional Liability Con
trol, MSNJ, was prepared by James E. George, M.D.. J.D.. and
A Ronald Rouse who are, respectively, Director of the Depart-
ment and Director of Special Projects.
1037
Question: “Would you support a no-fault system to
replace the tort system in California?”
Brown .- “Yes. Here is an opportunity to abandon self-
ish roles we play as individual advocates, looking out
basically for our own interests but always couching it
as if we’re looking out for someone else’s — the patient’s
or the victim’s. What we have is a social problem — of
people being injured and needing compensation— not
a crisis generated by one or two big verdicts.”
Brown said the entire system for compensating vic-
tims could collapse and expressed great concern about
social distribution that could occur as a result. “If you
are prepared to discuss contingency fees of lawyers at
the same table and in the same room where your pro-
fessional fees are discussed, I would agree to that. The
public, of course, would like to see us in that kind of
a contest because they think we all charge too much.”
(Medical Liability Monitor, Vol. 9, No. 7, July 25, 1984)
DID YOU KNOW . . .
A California disciplinary board could be prevented
from discouraging treatment it considers unsafe? The
Jehovah’s Witnesses have won the right to sue the
state for violating their religious freedom by discourag-
ing doctors from performing “bloodless” surgery. That,
the Witnesses say, infringes on their First Amendment
rights, since group members refuse blood transfusions
as a matter of religious belief. ( Medical Economics,
May 28, 1984)
As the role of professional review organizations
changes under Medicare’s prospective-payment sys-
tem, physicians will become more vulnerable to lia-
bility claims, PRO directors warn? For example, if a
review board determines that a physician performed
unnecessary surgery, the Medicare patient will be
notified. The result could be a malpractice suit against
the doctor. PROs recommend that doctors take this
precaution: Get your review board’s approval of the
procedure before surgery. ( Medical Economics, July 9,
1984)
Medical liability rates increased last year as the fre-
quency and severity of malpractice claims continued
to rise, according to the American Medical Assurance
Co.? The average loss by settlement or judgment rose
approximately 20 percent. As a result, 22 physician-
owned companies raised premiums ranging from 6 to
30 percent adding at least $60 million to the overall
cost of medical liability insurance. In 1984, at least K
physician companies already have increased ratet
again. The increases range from 6 to 39 percent
Others will increase premiums before the end of tht
year. (AMA Newsletter, Vol. 16, No. 19, May 22, 1984
AWARD TO DEAF CHILD
The state was liable for $1,500,000 for medica
malpractice for the negligent evaluation and treatmen
of a deaf child at a state school, a New York appellatt
court ruled.
The patient was bom prematurely on August 20
1962, to a mother who had a family history of epilepsy
After repeated hospitalizations, he was institu
tionalized. His medical records indicated that his hear
ing was questionable. A Kuhlmann I.Q. test was admin
istered and he recorded a score of 24. On the basis o
that test score, he was considered not suitable for i
trainable and educable program.
In May 1967, he was enrolled in a speech class. His
teacher labeled him as a “very bright" child who coulc
“learn quickly.” In August 1967, he was described ai|
an interested youngster who was extrememly alert bu
deaf. Despite those observations inconsistent with hit
recorded I.Q. of 24, he was not re-evaluated intellectual
ly until June 1971. In November 1976, a claim waf
brought against the state of New York by the patient
both individually and by his parent and natural guard
ian, to recover damages emanating from the patient’s
admission and confinement at one state school frorr
June 1965 to August 1972, and at another state schoo
from August 1972 to December 31, 1974. A trial cour
found that the state committed medical malpracticf
and awarded the patient $2,500,000 as compensatior
for the lost years of proper training.
Reducing the award to $1,500,000, the appellati
court said the trial court’s award was an exorbitan
amount reflecting the court’s sympathy. The court ac
curately determined that the state’s action was medi
cal malpractice, rather than educational malpractice
for which there was no action. Failure to conduct a re
evaluation of the patient’s classification as an imbecili
with any degree of diligence departed from accepte(
medical standards and was malpractice, the cour
said — Snow v State of New York, 469 N.Y.S.2d 959 (N.Y
Sup. Ct„ App. Div., Dec. 27, 1983). (The Citation, Vol
49, No. 6, July 1, 1984)
.
I
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1038
New low price...major savings
The dramatic reduction in the price ot Motrin Tablets means substantial savings
from now on for your patients and for patients all across the country for whom Motrin
Tablets are prescribed.
Motrin is priced lower than Clinoril, Feldene, or Naprosyn.
The price of Motrin Tablets to pharmacies has been reduced as much as 35%.
Patients taking the average dosage should now pay less for therapy with Motrin Tablets
than for almost any other nonsteroidal anti-inflammatory drug you
prescribe... less, for example, than for Clinoril, Feldene, or Naprosyn. And, of course,
all strengths of Motrin Tablets continue to be available by prescription only.
Please see the following page for a brief summary of prescribing information.
Motrin
ibuorofen
TABLETS
mg
Good medicine...good value
© 1984 The Upjohn Company The Upjohn Company
Kalamazoo, Michigan 49001
L 81— NUMBER 12— DECEMBER 1984
1039
Motrin*1 Tablets (ibuprofen)
Contraindications: Anaphylactoid reactions have occurred in individuals hypersensitive to
Motrin Tablets or with the syndrome of nasal polyps, angioedema and bronchospastic reactivity
to aspirin, iodides, or other nonsteroidal anti-inflammatory agents.
Warnings: Peptic ulceration and Gl bleeding, sometimes severe, have been reported. Ulceration,
perforation and bleeding may end fatally. An association has not been established. Use Motrin
Tablets under close supervision in patients with a history of upper gastrointestinal tract disease,
after consulting ADVERSE REACTIONS, In patients with active peptic ulcer and active
rheumatoid arthritis, try nonulcerogemc drugs, such as gold. If Motrin Tablets are used, observe
the patient closely for signs of ulcer perforation or Gl bleeding
Chronic studies in rats and monkeys have shown mild renal toxicity with papillary edema and
necrosis. Renal papillary necrosis has rarely been shown in humans treated with Motrin Tablets.
Precautions: Blurred and/or diminished vision, scotomata, and/or changes in color vision have
been reported. If these develop, discontinue Motrin Tablets and the patient should have an
ophthalmologic examination, including central visual fields and color vision testing.
Fluid retention and edema have been associated with Motrin Tablets; use with caution in patients
with a history of cardiac decompensation or hypertension. In patients with renal impairment,
reduced dosage may be necessary. Prospective studies of Motrin Tablets safety in patients with
chronic renal failure have not been done.
Motrin Tablets can inhibit platelet aggregation and prolong bleeding time. Use with caution in
persons with intrinsic coagulation defects and on anticoagulant therapy.
Patients should report signs or symptoms of gastrointestinal ulceration or bleeding, skin rash,
weight gain, or edema.
Patients on prolonged corticosteroid therapy should have therapy tapered slowly when Motrin
Tablets are added
The antipyretic, anti-inflammatory activity of Motrin Tablets may mask inflammation and fever.
As with other nonsteroidal anti-inflammatory drugs, borderline elevations of liver tests may
occur in up to 15% of patients. These abnormalities may progress, may remain essentially
unchanged, or may be transient with continued therapy Meaningful elevations of SGPT or SGOT
(AST) occurred in controlled clinical trials in less than 1% of patients. Severe hepatic reactions,
including |aundice and cases of fatal hepatitis, have been reported with ibuprofen as with other
nonsteroidal anti-inflammatory drugs. If liver disease develops or if systemic manifestations
occur (e g eosinophilia, rash, etc.), Motrin should be discontinued
Drug interactions. Aspirin: used concomitantly may decrease Motrin blood levels.
Coumarm bleeding has been reported in patients taking Motrin and coumarin.
Pregnancy and nursing mothers: Motrin should not be taken during pregnancy or by nursing
mothers.
Adverse Reactions: The most frequent type of adverse reaction occurring with Motrin is
gastrointestinal of which one or more occurred in 4% to 16% of the patients.
Incidence Greater than 1 % (but less than 3%)— Probable Causal Relationship
Gastrointestinal: Nausea* epigastric pain* heartburn* diarrhea, abdominal distress, nausea
and vomiting, indigestion, constipation, abdominal cramps or pain, fullness of Gl tract (bloating
and flatulence); Central Nervous System: Dizziness* headache, nervousness; Dermatologic:
Rash* (including maculopapular type), pruritus; Special Senses: Tinnitus; Metabolic/Endocrine:
Decreased appetite; Cardiovascular: Edema, fluid retention (generally responds promptly to
drug discontinuation; see PRECAUTIONS).
Incidence less than 1%-Probable Causal Relationship**
Gastrointestinal: Gastric or duodenal ulcer with bleeding and/or perforation, gastrointestinal
hemorrhage, melena, gastritis, hepatitis, |aundice, abnormal liver function tests; Central
Nervous System: Depression, insomnia, confusion, emotional lability, somnolence, aseptic
meningitis with fever and coma, Dermatologic: Vesiculobullous eruptions, urticaria, erythema
multiforme, Stevens-Johnson syndrome, alopecia; Special Senses: Hearing loss, amblyopia
(blurred and/or diminished vision, scotomata, and/or changes in color vision) (see PRECAU-
TIONS); Hematologic: Neutropenia, agranulocytosis, aplastic anemia, hemolytic anemia (some-
times Coombs positive), thrombocytopenia with or without purpura, eosinophilia, decreases in
hemoglobin and hematocrit, Cardiovascular: Congestive heart failure in patients with marginal
cardiac function, elevated blood pressure, palpitations; Allergic: Syndrome of abdominal pain,
fever, chills, nausea and vomiting; anaphylaxis; bronchospasm (see CONTRAINDICATIONS);
Renal: Acute renal failure in patients with pre-existing significantly impaired renal tunction,
decreased creatinine clearance, polyuria, azotemia, cystitis, hematuria. Miscellaneous: Dry eyes
and mouth, gingival ulcer, rhinitis.
Incidence less than 1%-Causal Relationship Unknown**
Gastrointestinal: Pancreatitis; Central Nervous System: Paresthesias, hallucinations, dream
abnormalities, pseudotumor cerebri; Dermatologic: Toxic epidermal necrolysis, photoallergic
skin reactions; Special Senses: Coniunctivitis, diplopia, optic neuritis; Hematologic: Bleeding
episodes (e.g„ epistaxis, menorrhagia), Metabolic/Endocrine: Gynecomastia, hypoglycemic
reaction; Cardiovascular: Arrhythmias (sinus tachycardia, sinus bradycardia); Allergic: Serum
sickness, lupus erythematosus syndrome, Henoch-Schonlein vasculitis; Renal: Renal papillary
necrosis.
♦Reactions occurring in 3% to 9% of patients treated with Motrin. (Those reactions occurring in
less than 3% of the patients are unmarked.)
♦♦Reactions are classified under Probable Causal Relationship (PCR)" if there has been one
positive rechallenge or if three or more cases occur which might be causally related. Reactions
are classified under "Causal Relationship Unknown" if seven or more events have been reported
but the criteria for PCR have not been met.
Overdosage: In cases of acute overdosage, the stomach should be emptied. The drug is acidic
and excreted in the urine so alkaline diuresis may be beneficial.
Dosage and Administration: Rheumatoid arthritis and osteoarthritis. Suggested dosage is 300,
400, or 600 mg t.i.d. or q.i.d. Do not exceed 2400 mg per day. Mild to moderate pain: 400 mg
every 4 to 6 hours as necessary.
Caution: Federal law prohibits dispensing without prescription. med b-7-s
Motrin is a registered trademark of The Upjohn Manufacturing Company.
Upjohn
The Upjohn Company
Kalamazoo, Michigan 49001
Helping Medical
Management Manage
Sixteen years ago, Mary Ann Hamburger of
Maplewood took a job for a doctor managing
his office. Today, as a medical management
consultant, Mary Ann Hamburger Assoc. 's
responsibilities include making sure everything
runs smoothly for the physician and his or her
staff.
Part of her job is to make certain that the
current billing system is working efficiently, to
update the filing system, to clear up any book-
ing problems as far as appointments are
concerned and any problems relating to the
management or business side of a medical
practice.
Mary Ann Hamburger Assoc, will benefit any
doctor in an existing practice having a problem
with the business aspect of his or her practice
and all new doctors who plan to set up practice
in the near future. Her service can also include
the hiring aspect of doctors’ offices, if desired.
Further information on medical management
is available from Mary Ann at
201-763-7394
ta V C|jp| TpDC
Just one of the personal
financial services
available to you from the
physician’s bank.
• tax planning
• lines of credit
• equipment financing
• retirement planning
• money management
• cash flow • investments
• estate planning
i
Cali or Write
Joseph J. Verbaro, Jr.
Senior Vice President
(201) 228-9770
■MTRU5T
FINANCIAL AND TRUST SERVICES ~~J
DIVISION OF SECURITY NATIONAL BANK & TRUST COMPANY
OF NEW JERSEY
\
101 Eisenhower Parkway
Roseland, New Jersey 07068
f
It
Member F.D.I.C
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
1040
EDITORIAL
[s There a Doctor in the
House?
Frank J. Primich, m.d.
The cost crisis in health care has created
a variety of problems. And something
must be done. Can physicians help solve
some of these problems?
—
Traditionally, when problems
arose regarding illness or injury,
the first opinion sought was
l at of a physician. Currently, the “cost crisis” in
1 alth care has spawned a plethora of instant experts.
' iey range from politicians to Ph.Ds. The few token
I Ds consulted either are far removed from direct pa-
pnt care or are obligated to present a cooperative
psition to make the best of a bad situation.
Lawyers and consumer advocates have had a field
| ly exploiting the side effects of medications and oper-
ive procedures. Since there is nothing in life which
: risk-free, cost-free, or free of responsibility, every
i cision must reflect the risk-benefit ratio involved.
When one considers alternatives in treatment in-
uding no treatment, the factors of risk, cost and
i fort must be balanced against the benefit to be de-
:/ed. The concept of informed consent assumes
/areness of predictable risks and costs, and reason-
>le expectations regarding results. Ideally, such de-
1 sions are best made by the patient and the physician,
ltiy of a third party, be it government or private
surer, injects a different set of value judgments.
The Utopian vision of high-quality health care for all
nericans is a desirable, though actuarially impos-
3le, goal. The irresponsible political promise of such
t /els of care sowed the seeds of our dilemma Entrap-
ent by government has drawn harsh criticism in the
Dscam and DeLorean cases, wherein individuals suc-
imbed to the lure of illegal profit. In health care, the
itrapment consisted of encouraging “legal” expen-
1 tures on overexpansion, overutilization, and mar-
nally beneficial technological advances. While there
idoubtedly were some who improperly, illegally, or
amorally exploited the system, the vast majority simp-
abided by the rules and guidelines of the era
Excessive costs eventually became apparent. Mis-
directing the blame was a political imperative. Such
misdiagnosis precludes any adequate cure.
The crisis atmosphere associated with the impend-
ing bankruptcy of Social Security dominated domestic
concerns through prolonged bipartisan negotiations
of a “solution.” Medicare's instability of similar propor-
tions was “resolved” as an afterthought Changes were
introduced with no substantive evidence of supposed
benefits, nor consideration of predictable damages.
Diagnosis Related Groups (DRGs) originated as a
method of cost analysis. Conversion to a reimburse-
ment methodology was fraught with potential hazards.
DRGs best are described as an illogical, impersonal,
and often inhumane system directed almost exclusive-
ly to cost containment with an inevitable negative
impact upon quality and availability of health care.
Incremental introduction is akin to the “frog in boiling
water” analogy. The gradual change is met by accom-
modation until it is too late to escape the end result.
New Jersey’s federally sponsored “experiment” with
DRGs began in 1980. MSNJ’s concerns were allayed by
the promise that the program would be limited and
voluntary. When it was arbitrarily expanded to a man-
datory all-inclusive system, objections and warnings
from practicing physicians fell on deaf ears. My testi-
mony before government committees was disregarded.
It was announced that “something had to be done,”
and any untoward side effects would be addressed
when they occurred.
The prime impetus to passage of the regulations was
the unsubstantiated claim of success by the New Jer-
sey State Department of Health. To this day, there has
been no appreciable evidence to support that claim. It
was ironic that the federal Health Care Financing Ad-
ministration now has refused to extend the New Jersey
waiver because of “excessive cost increases.” Actually,
the charge is inaccurate. It evolved from one of the
many apple and orange comparisons that our reliance
on computerized statistics fosters. The figures are
compiled, at great expense, using different units of
measurement which ensure the favorable or un-
favorable bottom line being sought. The academicians
have little comprehension of the human values in-
volved. The appalling inaccuracy of their projections
deserves further condemnation.
Arbitrary determination of the appropriate per-
centage of GNP to be allotted to health care is presump-
tuous. Most individuals gladly would expend more
than 10.5 percent of their gross product to maintain
or regain their health. Billions are spent on fads and
quackery. When a problem is vital and personal, cost
considerations become secondary. Assuming the
citizenry to be incompetent of exercising free choice
and individual responsibility regarding health care
portends confiscation of our other liberties. Decisions
made by dictate or lotteiy will shatter forever our
treasured illusion of self-determination.
Meanwhile, enslavement of physicians under social-
ized medicine will deter the entry of students into the
study and practice of medicine. Computers may fill the
void for a while, but the day will come when the urgent
cry, “Is there a doctor in the house?" will be answered
by an eerie silence.
0L. 81— NUMBER 12— DECEMBER 1984
1041
First-step blood pressure control
with optimal simplicity
Benefits diuretics cannot offer. . .Once-daily inderal la
(propranolol hydrochloride) with its smooth 24-hour control of blood
pressure provides a high degree of patient acceptance without potas-
sium problems, plus the cardiovascular benefits of the world’s leading-
beta blocker.
Experience no other beta blocker can match. . . Once-daily
INDERAL LA delivers the proven performance and safety profile of
INDERAL tablets — confirmed by millions of patients during 16 years
of clinical use. INDERAL LA should not be used in congestive heart
failure, sinus bradycardia, heart block greater than first degree, or
bronchial asthma.
Start with 80 mg once daily . . . Dosage may be increased to
120 mg or 160 mg once daily as needed to achieve additional control
Please see next page for further details and brief summary of
prescribing information.
80 120 160
mg mg mg
The appearance of INDERAL LA capsules
is a registered trademark of Ayerst Laboratories
Just once each day
for initial therapy in
HYPERTENSION.
ONCE-DAILY
INDERAL LA
(PROPRANOLOL HOI)
LONG ACTING
CAPSULES
80
mg
120
mg
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULAR.)
INDERAL' LA brand of propranolol hydrochloride (Long Acting Capsules)
DESCRIPTION. Inderal LA is formulated to provide a sustained release of propranolol
hydrochloride Inderal LA is available as 80 mg. 120 mg, and 160 mg capsules
CLINICAL PHARMACOLOGY. INDERAL is a nonselective beta-adrenergic receptor
blocking agent possessing no other autonomic nervous system activity It specifically com-
petes with beta-adrenergic receptor stimulating agents for available receptor sites. When
access to beta-receptor sites is blocked by INDERAL, the chronotropic, inotropic, and
vasodilator responses to beta-adrenergic stimulation are decreased proportionately.
INDERAL LA Capsules (80, 120, and 160 mg) release propranolol HCI at a controlled and
predictable rate. Peak blood levels following dosing with INDERAL LA occur at about 6 hours
and the apparent plasma half-life is about 10 hours When measured at steady state over a 24-
hour period the areas under the propranolol plasma concentration-time curve (AUCs) for the
capsules are approximately 60% to 65% of the AUCs for a comparable divided daily dose of
INDERAL tablets The lower AUCs for the capsules are due to greater hepatic metabolism of
propranolol, resulting from the slower rate of absorption of propranolol. Over a twenty-four (24)
hour period, blood levels are fairly constant for about twelve (12) hours then decline
exponentially.
INDERAL LA should not be considered a simple mg for mg substitute for conventional
propranolol and the blood levels achieved do not match (are lower than) those of two to four
times daily dosing with the same dose. When changing to INDERAL LA from conventional
propranolol, a possible need for retitration upwards should be considered especially to
maintain effectiveness at the end of the dosing interval. In most clinical settings, however,
such as hypertension or angina where there is little correlation between plasma levels and
clinical effect, INDERAL LA has been therapeutically equivalent to the same mg dose of
conventional INDERAL as assessed by 24-hour effects on blood pressure and on 24-hour
exercise responses of heart rate, systolic pressure and rate pressure product INDERAL LA
can provide effective beta blockade for a 24-hour period.
The mechanism of the antihypertensive effect of INDERAL has not been established.
Among the factors that may be involved in contributing to the antihypertensive action are (1)
decreased cardiac output, (2) inhibition of renin release by the kidneys, and (3) diminution of
tonic sympathetic nerve outflow from vasomotor centers in the brain. Although total peripheral
resistance may increase initially, it readjusts to or below the pretreatment level with chronic
use Effects on plasma volume appear to be minor and^jnewhat variable INDERAL has
been shown to cause a small increase in serum potassiiMficoncentration when usecjppthe
treatment of hypertensive patients f- _ „ JML—
In angina pectoris, propranolol generally reduces retMt^^W^pS^^prat
any given level of effort by blocking the catecholamme^i^Sb incaBHSLnthe heatjfrate.
systolic blood pressure, and the velocity and extent of.;|^o<Sardiai ®1tra^3ft^ra^fanolol
may increase oxygen requirements by increasing leftspltri^ular titrflengfrf'^^f®stolic
pressure and systolic election period The net physiologic effect ul oeta-adiwrurgic blockade
is usually advantageous and is manifested during e^rcisPiay-defayed rWsef 'ol pain and
increased work capacity JBf
In dosages greater than required for beta blockade INDERAL also exerts a quinidine-Hf
or anesthetic-like membrane action which affects the cardujc action poicntiaL The jg
cance ol the membrane action in the treatment of .jrrhvthmr^i^friceria
The mechanism of the antimigraine etlect of propranotot has not beeAfS^pjlisherr
adrenergic receptors have been demonstrated in the ptaf vessels of the brain
Beta receptor blockade can be useful in condtjOns iryarfrich, because of path
functional changes, sympathetic activity is detrimental to the patiert. Bn’ there
situations in which sympathetic stimulation is vital Forexample\1n patients wtfn severely
damaged hearts, adequate ventricular function is maintained by virtue of sympathetic drive
which should be preserved In the presence of A V block, greater than first degree, beta
blockade may prevent the necessary facilitating effect of sympathetic activity on conduction.
Beta blockade results in bronchial constriction by interfering with adrenergic bronchodilator
activity which should be preserved in patients subject to bronchospasm.
Propranolol is not significantly dialyzable
INDICATIONS AND USAGE. Hypertension: INDERAL LA is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL LA is not Indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated
for the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA Is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL LA also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta-receptor stimulation.
Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL is contraindicated in 1) cardiogenic shock; 2) sinus
bradycardia and greater than first degree block; 3) bronchial asthma; 4) congestive heart
failure (see WARNINGS) unless the failure is secondary to a tachyarrhythmia treatable with
INDERAL
WARNINGS. CARDIAC FAILURE: Sympathetic stimulation may be a vital component sup-
porting circulatory function in patients with congestive heart failure, and its inhibition by beta
blockade may precipitate more severe failure. Although beta blockers should be avoided in
overt congestive heart failure, if necessary, they can be used with close follow-up in patients
with a history of failure who are well compensated and are receiving digitalis and diuretics.
Beta-adrenergic blocking agents do not abolish the inotropic action of digitalis on heart
muscle.
IN PATIENTS WITFIOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure. Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and. in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks, and the patient should be
cautioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications.
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking thlj
prior to ma|or surgery is controversial. It should be noted, however, that the impaired ab!u
the heart to respond to reflex adrenergic stimuli may augment the risks of general aneshjj
and surgical procedures.
INDERAL (propranolol HCI), like other beta blockers, is a competitive inhibitor ol .j.
receptor agonists and its effects can be reversed by administration of such agents; j,
dobutamme or isoproterenol However, such patients may be subject to protracted s;l
hypotension. Difficulty in starting and maintaining the heartbeat has also been reporieCjj
b6t3 blockers
DIABETES AND HYPOGLYCEMIA: Beta-adrenergic blockade may prevent th 3
pearance of certain premonitory signs and symptoms (pulse rate and pressure chang 0
acute hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be »
difficult to ad|ust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroi n
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of symi: |
of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function i
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have i
reported in which, after propranolol, the tachycardia was replaced by a severe bradycj#
requiring a demand pacemaker. In one case this resulted after an initial dose of
propranolol
PRECAUTIONS. General . Propranolol should be used with caution in patients with imp I
hepatic or renal function INDERAL is not indicated for the treatment of hyperte *
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure Pa Is
should be told that INDERAL may interfere with the glaucoma screening test Withdrawajr,
lead to a return of increased intraocular pressure.
Clinical Laboratory Tests: Elevated blood urea levels In patients with severe heart disja
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as
pine should be closely observed if INDERAL is administered. The added catechola
blocking action may produce an excessive reduction of resting sympathetic nervous ai
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or ortho
hypotension
Carcinogenesis, Mutagenesis. Impairment ol Fertility Long-term studies in animals
been conducted to evaluate toxic effects and carcinogenic potential In 18-month stud
both pats aad rTus^emnlcftat^kdoses^atol 50 mg/kg/day. there was no evidence of signi
drug-induced toxicity There wen’ no drug-related tumorigemc effects at any of the dc
neve^pBmyduc|WJBaies ariimals did not show any impairment of fertility tha
attributable 10 the drug.
-mmincY
diwnaTstudies ati _
Th&to';are ndtodeql
be used during 1
Nursing Mot)
DERA ~
"’"“'icl
VERSE RE
ry C JNDERAL has been shown to be embryoto
_ er than the maximum recommended human
rolled studies in pregnant women. INDERAL si
jnancy only if the potential benefit |ustifies the potential risk to the t
is INDERAL is excreted in human milk Caution should be exercised r
ss in children have not been established,
effects have been mild and transient and
^KSUve heart failure, intensification of AV block,
ocytopemc purpura; arterial insufficiency, usually If
laua’Type — - jm
Central Nervous Sysfem^^pheadedness, mental depression manifested by insoll
lassitude, weakness, fatigu^iversible mental depression progressing to catatonia, a
disturbances, hallucinations; an acute reversible syndrome characterized by disorientatijir
time and place, short-term memory loss, emotional lability, slightly clouded sensorium I
decreased performance on neuropsychometrics.
Gastrointestinal, nausea, vomiting, epigastric distress, abdominal cramping, diai I
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with a jj
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm
Flematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytoiit
purpura
Auto immune: In extremely rare instances, systemic lupus erythematosus has jf
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male k
tence, and Peyronie’s disease have been reported rarely Oculomucocutaneous rears
involving the skin, serous membranes and con|unctivae reported for a beta blocker (pracjl
have not been associated with propranolol
DOSAGE AND ADMINISTRATION. INDERAL LA provides propranolol hydrochloride
sustained-release capsule for administration once daily If patients are switched from IND/ 1
tablets to INDERAL LA capsules, care should be taken to assure that the desired theradl
effect is maintained INDERAL LA should not be considered a simple mg for mg substiti I
INDERAL INDERAL LA has different kinetics and produces lower blood levels. Retitratioi II
be necessary especially to maintain effectiveness at the end of the 24-hour dosing inti*
HYPERTENSION — Dosage must be individualized The usual initial dosage is 8 j
INDERAL LA once daily, whether used alone or added to a diuretic. The dosage mijj
increased to 120 mg once daily or higher until adequate blood-pressure control is achijl
The usual maintenance dosage is 120 to 160 mg once daily. In some instances a dosage i t
mg may be required The time needed for full hypertensive response to a given dosrjii
variable and may range from a few days to several weeks
ANGINA PECTORIS— Dosage must be individualized. Starting with 80 mg INDER/sj
once daily, dosage should be gradually increased at three to seven day intervals until opt ™
response is obtained Although individual patients may respond at any dosage levdl
average optimum dosage appears to be 160 mg once daily In angina pectoris, the valu .K
safety of dosage exceeding 320 mg per day have not been established
If treatment is to be discontinued, reduce dosage gradually over a period of a few v:l
(see WARNINGS) (J
MIGRAINE — Dosage must be individualized The initial oral dose is 80 mg INDER/ 1 '
once daily. The usual effective dose range is 160-240 mg once daily The dosage m;j<
increased gradually to achieve optimum migraine prophylaxis. If a satisfactory responseij
obtained within four to six weeks after reaching the maximum dose. INDERAL LA th 1
should be discontinued It may be advisable to withdraw the drug gradually over a peril1
S0V0C3I \/V66kS
HYPERTROPHIC SUBAORTIC STENOSIS— 80-160 mg INDERAL LA once daily i
PEDIATRIC DOSAGE— At this time the data on the use of the drug in this age group aJ
limited to permit adequate directions for use
*The appearance of INDERAL LA capsules is a registered trademark of Ayerst Labora"
895(7
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema) —
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA
BLOCKERS. INDERAL should be administered with caution since it may block bronchodila-
tion produced by endogenous and exogenous catecholamine stimulation of beta receptors.
Ayerst
AYERST LABORATORIES
New York, N.Y. 10017
1044
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE,
Iospital Governing
joards*
Federal Prospective
Payment and the NJ
Demonstration Waiver
Vincent A. Maressa, j.d.
The time has come for hospitals, the
Health Department, and the legislature
to find a solution to the problem oj the
New Jersey demonstration waiver.
!
The Administrator of the Health
Care Financing Administration,
Carolyne K. Davis, Ph.D., noti-
ed the Commissioner of Health that the federal dem-
nstration waiver from the Seeretaiy of Health and
uman Services for the experimental cost control pro-
ram being conducted in New Jersey was revoked, ef-
xdive December 31, 1984. In her letter. Dr. Davis in-
licated that the New Jersey program failed to demon-
ijtrate it was less expensive than the federal form of
reimbursement. Dr. Davis then gave the Health Depart-
lent two options: 1) go into the federal system on
anuaiy 1, 1985, or 2) qualify for a new waiver
ursuant to the Social Security Amendments of 1983.
The Commissioner of Health and the New Jersey
Pfospital Association maintain that option #2 is the
nly viable course for New Jersey to follow. In order for
ew Jersey to qualify, however, a number of criteria
lust be met. These are:
1. The program must apply to substantially all acute
are hospitals in the state and review at least 75 per-
OL. 81— NUMBER 12— DECEMBER 1984
cent of all inpatient revenues or expenses of those
hospitals. (Comment: New Jersey should be able to
meet this standard.)
2. The program must provide equitable treatment to
all payors, hospital employees, and patients. (Current
actions in New Jersey afford different rules to different
payors, i.e. union funds are “self-payors” and by pass-
ing payments through the patient can opt for DRG
rates or charges, “self-payors,” i.e. people with an un-
insured exposure exceeding $250 can opt for charges,
prompt payors get a discount. Blue Cross gets a
prompt payor, and community service discount. (Com-
ment: Whether this is “equitable” and meets the legal
standard is a matter for debate.)
3. The program must not cost the federal govern-
ment more than the federal DRG system would cost
over a three-year period. (Comment: Since New Jersey
produces about 35 percent outliers and provides com-
pensation for indigent and teaching costs not covered
in the federal program, compliance here is doubtful.)
4. The program must permit health maintenance
organizations or other competitive medical plans to
negotiate directly with hospitals concerning rates for
inpatient services. (Comment: This requirement
creates havoc with the all-payor concept and will
produce a further cost shift by having Medicare and
Medicaid pay a greater portion of indigent care.)
5. The program must not result in admission prac-
tices that reduce the level of treatment provided to
uninsured low-income, high cost, or emergency pa-
tients. (Comment: New Jersey currently is meeting this
standard.)
6. The program must use prospective payment
methods. (Comment: This already is settled as a com-
ponent of our system.)
A state with an existing demonstration waiver would
have to meet the first 4 requirements listed above.
There are 1 1 statutory requirements in all, but I did
not believe the other 5 requirements necessaiy to this
discussion. Since the New Jersey waiver has been “re-
voked," it would appear that the Health Department
will have to submit an application that complies with
the 1 1 statutory requirements.
There is a further subtle twist to the law. The Sec-
retary of HHS cannot deny a waiver because Medicare
payments exceed federal Medicare costs. The Secretary
may reduce future Medicare payments to hospitals in
that state to recoup overpayments. Thus, the over-
payment would generate future credit lines, and the
hospitals involved could find themselves in a real cash
shortfall in future operating years.
Clearly, the current New Jersey practice of funding
indigent and teaching costs by extra charges to the
patients using our hospitals reduces the possibility of
any acceptable performance as a waivered state. The
time has come for all concerned hospitals, the Health
Department, and the legislature to find a realistic solu-
tion. That solution is likely to be unpopular since the
only workable one I can see is general tax revenue. I
do not like taxes: however, I do not believe we can
continue fooling ourselves.
*The material for this column is coedited by Arthur Krosnick,
M.D., Editor, The Journal. MSNJ; Vincent A. Maressa. J.D..
Executive Director. MSNJ; and James E. George. M.D., J.D..
Director of Professional Liability, MSNJ.
1045
COMPULSIVE
GAMBLING
i
first became involved with com-
pulsive gambling six years ago
in my first term as an As-
semblyman. A woman concerned that her husband
was gambling away the family’s income called me to
ask if there was anything I could do. She thought it
a shame that the state so actively promoted legalize
gambling and I agreed with her. I began looking in
gambling and as I learned more about compulsf
gamblers, the more I became involved in finding wa;
to help them.
Now, six years after that first talk, important pro.
By Assemblyman Chuck Hardwick, Westfield
1046
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
COMPULSIVE GAMBLING
bss has been made. A full-time office on compulsive
[ambling has been opened, several conferences on
Dmpulsive gambling have been held, and the public
t large has become more aware of this devastating
isease.
This year. New Jersey will derive roughly 7 percent
f its budget — or $521 million — from legalized gam-
ling. The basic tenet behind all my proposals to help
ompulsive gamblers is the belief that since the state
erives so much money from gambling, it has an obli-
ation to help those who are hurt by it. It seems like
uch a logical argument. But it has not been easy to
onvince legislators and state administrators to con-
ribute in some way to the treatment of compulsive
amblers.
In 1982, I successfully sponsored an appropriation
f $60,000 for seed money to begin a compulsive gam-
bler's treatment project in New Jersey. (In 1980 and
981, former Governor Brendan Byrne vetoed the ap-
ropriation.) The funds, signed into New Jersey's 1982
o 1983 state budget by Governor Thomas Kean, were
iven to the State Department of Health, which con-
racted with the National Council on Compulsive Gam-
ming to form a New Jersey chapter. Last year, I was
uccessful in having that appropriation increased to
5200,000.
The program has focused on making the public
Ware of the problem of compulsive gambling through
onferences, the press, and meetings with the private
.eetor. At present, it would not be economically feasible
or the state to fund a full medical treatment facility
or compulsive gamblers. But I currently am investigat-
,ng ways in which the gambling industry can help
ontribute to the present program; this may generate
, mough funds to open an outpatient clinic, perhaps in
Atlantic City.
Indeed, the past two years have seen a great deal of
rrogress in defining the problem of compulsive gam-
ming since the public approved of casino development
n Atlantic City in 1978. The casinos have contributed
n part to the frequency and visibility of compulsive
gambling. The next step is to determine what sort of
gambling procedures contribute to compulsive gam-
bling. One of the most devasting procedures, I believe,
s the way in which “casino credit” is distributed.
Simply, casino credit is money given to a gambler,
nterest free, so he can continue gambling after his
noney has run out. When one looks into the casino
l:redit issue, as I have done, one finds that casinos have
pwo types of credit: one for convenience; the other is
because the gambler is flat broke.
I learned this after I conducted my own investigation
jby visiting casino officials, talking to gamblers, and
working with a casino credit manager. I found that
casino credit is given much too freely, often without
regard for a person’s ability to repay. The State Com-
mission of Investigation, which conducted public hear-
ings on casino credit abuse last spring, discovered the
same sort of practices.
In an effort to remedy the casino credit situation, I
have proposed three pieces of legislation:
• The first would prohibit casinos from giving ad-
ditional credit to gamblers who already have checks or
markers that have been returned for insufficient funds
pending at any other casino. This would help prevent
an indebted gambler from hopping from casino to
casino to gamble himself further into debt or to borrow
money from one casino to pay his debt at another
casino.
• The second proposal would require casinos to
wait 24 hours between the time a person applies for
credit and the casinos issue it. This delay would allow
the gambler time to reflect on his or her desire to
continue gambling.
• My third proposal would remove the statute that
permits casinos to deduct up to 4 percent of their
winnings as uncollectable debts. This change would
create a greater incentive for casinos to extend credit
only to those who can repay. It would provide more
funds for the elderly and the handicapped, who are
helped by various programs through the Casino Rev-
enue Fund.
Another of my proposals would require the gambling
industry to contribute to the treatment of compulsive
gamblers. It would levy a $25 annual fee on each of the
nearly 12,000 slot machines in Atlantic City, all lottery
ticket machines, and parimutuel ticket machines. The
money would be used for the treatment of compulsive
gamblers. For the present year, I was successful in
negotiating an allocation of $75,000 to the University
of Medicine and Dentistry of New Jersey from the State
Lottery Commission to help fund a study to investigate
the causes of compulsive gambling. By law, lottery
money is distributed in part to higher education; these
funds were awarded to UMDNJ for compulsive gam-
bling research.
Legalized gambling is here to stay in New Jersey!
What we must do is to learn how best to conduct it.
A proposal of mine to form a Governor’s Advisory Com-
mittee on Gambling currently is before the New Jersey
Legislature. The Committee would consist of public
officials, mental health experts, former compulsive
gamblers, and other citizens who would study current
gambling practices, designate problem areas, and rec-
ommend solutions.
’Assemblyman Chuck Hardwick is the Minority Whip. Cor-
respondence may be addressed to Assemblyman Hardwick.
100 Quimby Street, Westfield. NJ 07090.
70L. 81— NUMBER 12— DECEMBER 1984
1047
On nitrates,
but angina still
strikes,..
I
'
;
1
!
!
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSI
1048
After a nitrate,
add ISOPTIN
(verapamil HCl/Knoll)
To protect your patients, as well as their quality of life,
add Isoptin instead of a beta blocker.
First, Isoptin not only reduces myocardial oxygen demand
by reducing peripheral resistance, but also increases coro-
nary perfusion by preventing coronary vasospasm and
dilating coronary arteries — both normal and stenotic.
These are antianginal actions that no beta blocker
can provide.
Second, Isoptin spares patients the
beta-blocker side effects that may
compromise the quality of life.
With Isoptin, fatigue, bradycardia and mental
depression are rare. Unlike beta blockers,
Isoptin can safely be given to patients with
asthma, COPD, diabetes or peripheral
vascular disease. Serious adverse
reactions with Isoptin are rare
at recommended doses; the
single most common side
effect is constipation (6.3%).
Cardiovascular contra-
indications to the use of
Isoptin are similar to those
of beta blockers: severe
left ventricular dysfunction,
hypotension (systolic pres-
sure <90 mm Hg) or cardio-
genic shock, sick sinus syndrome
(if no artificial pacemaker is present)
and second- or third-degree AV block.
So, the next time a nitrate is not enough, add
Isoptin ... for more comprehensive antianginal
protection without side effects which may
cramp an active life style.
ISOPTIN. Added
antianginal protection
without beta-blocker
side effects.
Please see brief summary on following page.
I
VOL. 81— NUMBER 12— DECEMBER 1984
1049
1S0PT1N ,.\wi,s
(verapamil HCl/Knoll)
80 mg and 120 mg
Contraindications: Severe left ventricular dysfunction (see Warn-
ings), hypotension (systolic pressure <90 mm Hg) or cardiogenic
shock, sick sinus syndrome (if no pacemaker is present), 2nd- or 3rd-
degree AV block. Warnings: ISOPTIN should be avoided in patients
with severe left ventricular dysfunction (e.g., ejection fraction <30%)
or moderate to severe symptoms of cardiac failure. Control milder
heart failure with optimum digitalization and/or diuretics before
ISOPTIN is used. ISOPTIN may occasionally produce hypotension
(usually asymptomatic, orthostatic, mild, and controlled by decrease
in ISOPTIN dose). Occasional elevations of liver enzymes have been
reported; patients receiving ISOPTIN should have liver enzymes moni-
tored periodically. Patients with atrial flutter/fibrillation and an acces-
sory AV pathway (e.g., W-P-W or L-G-L syndromes) may develop a
very rapid ventricular response after receiving ISOPTIN (or digitalis).
Treatment is usually D.C. -cardioversion. AV block may occur (3rd
degree, 0.8%). Development of marked 1 st-degree block or progres-
sion to 2nd- or 3rd-degree block requires reduction in dosage or,
rarely, discontinuation and institution of appropriate therapy. Sinus
bradycardia, 2nd-degree AV block, sinus arrest, pulmonary edema,
and/or severe hypotension were seen in some critically ill patients
with hypertrophic cardiomyopathy who were treated with ISOPTIN.
Precautions: ISOPTIN should be given cautiously to patients with
impaired hepatic function (in severe dysfunction use about 30% of
the normal dose) or impaired renal function, and patients should be
monitored for abnormal prolongation of the PR interval or other
signs of overdosage. Studies in a small number of patients suggest
that concomitant use of ISOPTIN and beta blockers may be beneficial
in patients with chronic stable angina. Combined therapy can also
have adverse effects on cardiac function. Therefore, until further
studies are completed, ISOPTIN should be used alone, if possible. If
combined therapy is used, patients should be monitored closely.
Combined therapy with ISOPTIN and propranolol should usually be
avoided in patients with AV conduction abnormalities and/or de-
pressed left ventricular function or in patients who have also recently
received methyldopa. Chronic ISOPTIN treatment increases serum
digoxin levels by 50% to 70% during the first week of therapy, which
can result in digitalis toxicity. The digoxin dose should be reduced
when ISOPTIN is given, and the patient carefully monitored. ISOPTIN
may have an additive hypotensive effect in patients receiving blood-
pressure-lowering agents. Disopyramide should not be given within
48 hours before or 24 hours after ISOPTIN administration. Until fur-
ther data are obtained, combined ISOPTIN and quinidine therapy in
patients with hypertrophic cardiomyopathy should probably be
avoided, since significant hypotension may result. Adequate animal
carcinogenicity studies have not been performed. One study in rats
did not suggest a tumorigenic potential, and verapamil was not
mutagenic in the Ames test. Pregnancy Category C: There are no
adequate and well-controlled studies in pregnant women. This drug
should be used during pregnancy, labor, and delivery only if clearly
needed. It is not known whether verapamil is excreted in breast milk;
therefore, nursing should be discontinued during ISOPTIN use.
Adverse Reactions: Hypotension (2.9%), peripheral edema (1.7%),
AV block: 3rd degree (0.8%), bradycardia: HR<50/min (1.1%), CHF
or pulmonary edema (0.9%), dizziness (3.6%), headache (1.8%),
fatigue (1.1%), constipation (6.3%), nausea (1.6%). The following
reactions, reported in less than 0.5%, occurred under circumstances
where a causal relationship is not certain: confusion, paresthesia,
insomnia, somnolence, equilibrium disorders, blurred vision, syncope,
muscle cramps, shakiness, claudication, hair loss, maculae, and spotty
menstruation. Overall continuation rate of 94.5% in 1,166 patients.
How Supplied: ISOPTIN (verapamil HCI) is supplied in 80 mg and
120 mg sugar-coated tablets. July 1982 2068
O KNOLL PHARMACEUTICAL COMPANY
knofl 30 NORTH JEFFERSON ROAD, WHIPPANY NEW JERSEY 07981
2195
1
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1050
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERS
COMPULSIVE GAMBLING
NEW JERSEY
COMBATS
COMPULSIVE
GAMBLING
The Council on Compulsive Gam-
bling of New Jersey, Inc., an af-
filiate of The National Council
| Compulsive Gambling, has been operational since
Lnuary 1983. An appropriation of funds in the 1983
‘w Jersey State budget provided money to hire a
i — —
By Robert
* - - ■ -
i
director and to establish the olfice oi The Council on
Compulsive Gambling of New Jersey. Inc. The Council
was incorporated as a private, nonprofit health agency
and has received a contract from the state ol New
Jersey to render a variety of services for the benefit ot
the general public affected by compulsive gambling
M. Klein
)L. 81— NUMBER 12— DECEMBER 1984
1051
COMPULSIVE GAMBLING
At a statewide meeting , The Council on Compulsive Gambling oj
New Jersey, Inc., highlighted its present programs, including a
24-hour hotline service and a state networking system. The
Council plans additional services to help compulsive gamblers
in the state.
and for the professional community which ministers
to them.
The Council has developed and promoted a state-
wide public education and information campaign. To
this end, several of our goals already are in place. Our
Trenton office provides agency and referral services
during business hours. We can be reached at
609-599-3299. Our hotline number for help in New
Jersey is functioning smoothly and successfully. Any-
one calling 800-G-A-M-B-L-E-R, 24 hours a day, seven
days a week, is put in contact with someone who
understands and can help. Network and cable TV,
radio and newspapers, and our own correspondence
and literature, publicize this number.
Approximately 150 persons attended our North Jer-
sey and South Jersey seminars, which were geared
toward training of professional care providers. Our
purpose was to heighten their awareness in identifi-
cation, and expertise in treating and referring com-
pulsive gamblers and their families.
Our First Annual Statewide Conference on Com-
pulsive Gambling took place on September 28, 1983.
We are gratified and proud that this landmark event
was a cooperative venture with the Medical Society of
New Jersey. The Council is indebted to Dr. David I.
Canavan, Medical Director of the Impaired Physicians
Program, for his great contributions to assure the suc-
cess of this day-long conference. More than 20
physicians along with psychologists, social workers, re-
habilitation counselors, and representatives from the
mental health and criminal justice systems were
attendance. Evaluation indicated that the presente
were very well received, and that areas vital to ti
attending professionals had been addressed.
The Council on Compulsive Gambling of New Jers
is involved in networking with a great many agencit
organizations, and community leaders, in order
serve better the citizens of New Jersey.
A Blue Ribbon Task Force on Compulsive Gamblii
has been established to develop a dialogue among
wide spectrum of professional disciplines. It is hop*
that an awareness of this hidden illness will be cor
municated to the constituencies of this Task Fore
Input from the Task Force members will be invaluab
in helping The Council to reach its objectives ar
goals.
The Council is working to collect data on the gar
bling problem in New Jersey. For example, one r
markable statistic is that in 1982, of the 250, 0(
people brought to Atlantic City by a chartered bt
company, 75 percent of the passengers were sent
citizens. We particularly must consider the needs
students and women.
We owe so very much to so many: our staff. Boa.
of Directors, Advisory Board, Council members, ar
friends.
*Mr. Klein is Executive Director, The Council on Compulsi
Gambling of New Jersey, Inc., Trenton.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
1052
BALANCED
CALCIUM
Low incidence of side effects
3ARDIZEM® (diltiazem HC1)
produces an incidence of adverse
reactions not greater than that
reported with placebo therapy,
thus contributing to the patient’s
sense of well-being.
lardizem is indicated in the treatment of angina pectoris due to
coronary artery spasm and in the management of chronic stable
tngina (classic effort-associated angina) in patients who cannot
derate therapy with beta-blockers and/or nitrates or who remain
symptomatic despite adequate doses of these agents.
References:
L Strauss WE, McIntyre KM, Parisi AF, et al: Safety and efficacy
of diltiazem hydrochloride for the treatment of stable angina
pectoris: Report of a cooperative clinical trial. Am J Card 1 ql
49:560-566, 1982.
3. Pool PE, Seagren SC, Bonanno JA, et al: The treatment of exercise
inducible chronic stable angina with diltiazem: Effect, on treadmill
j exercise. Chest 78 (July suppl):234-238, 1980.
Reduces angina attack frequency*
42% to 46% decrease reported in
multicenter study.1
Increases exercise tolerance*
In Bruce exercise test,2 control
patients averaged 8.0 minutes to
onset of pain; Cardizem patients
averaged 9.8 minutes (PC.005).
CARDIZEM
(diltiazem HC1)
THE BALANCED
CALCIUM CHANNEL BLOCKER
Please see full prescribing information on following page.
2/84
PROFESSIONAL USE INFORMATION
cardizem,
(dilhazem HCI)
30 mg and 60 mg tablets
DESCRIPTION
CARDIZEM" (diltiazem hydrochloride) Is a calcium ion influx
inhibitor (slow channel blocker or calcium antagonist) Chemically,
diltiazem hydrochloride is 1,5-Benzothiazepm-4(5H)one.3-(acetyloxy)
-5-[2-(dimethylamino)ethyl |-2,3 dihydro 2-(4-methoxyphenyl)-.
monohydrochloride,( + ) -cis- The chemical structure is:
Diltiazem hydrochloride is a white to off-white crystalline powder
with a bitter taste. It is soluble in water, methanol, and chloroform
It has a molecular weight of 450.98. Each tablet of CARDIZEM
contains either 30 mg or 60 mg diltiazem hydrochloride for oral
administiatlon
CLINICAL PHARMACOLOGY
The therapeutic benefits achieved with CARDIZEM are believed
to be related to its ability to inhibit the Influx of calcium ions
during membrane depolarization of cardiac and vascular smooth
muscle
Mechanisms of Action. Although precise mechanisms of its
antianginal actions are still being delineated, CARDIZEM is believed
to act in the following ways:
1. Angina Due to Coronary Artery Spasm: CARDIZEM has been
shown to be a potent dilator of coronary arteries both epicardial
and subendocardial. Spontaneous and ergonovine-induced cor-
onary artery spasm are inhibited by CARDIZEM
2. Exertional Angina: CARDIZEM has been shown to produce
increases in exercise tolerance, probably due to its ability to
reduce myocardial oxygen demand. This is accomplished via
reductions in heart rate and systemic blood pressure at submaximal
and maximal exercise work loads.
In animal models, diltiazem interfeies with the slow inward
(depolarizing) current in excitable tissue It causes excitation-contraction
uncoupling in various myocardial tissues without changes in the
configuration of the action potential. Diltiazem produces relaxation
of coronary vascular smooth muscle and dilation of both large and
small coronary arteries at drug levels which cause little or no
negative inotropic effect The resultant increases in coronary blood
flow (epicardial and subendocardial) occur in ischemic and nonischemic
models and are accompanied by dose-dependent decreases in sys-
temic blood pressure and decreases in peripheral resistance
Hemodynamic and Electrophysiologic Effects. Like other
calcium antagonists diltiazem decreases sinoatrial and atrioventricu-
lar conduction in isolated tissues and has a negative inotropic effect
in isolated preparations. In the intact animal, prolongation of the AH
interval can be seen at higher doses.
In man, diltiazem prevents spontaneous and ergonovine-provoked
coronary artery spasm It causes a decrease in peripheral vascular
resistance and a modest fall in bluod pressure and, in exercise
tolerance studies in patients with ischemic heart disease, reduces
the heart rate-blood pressure product for any given work load.
Studies to date, primarily In patients with good ventricular function,
have not revealed evidence of a negative inotropic effect: cardiac
output, ejection fraction, and left ventricular end diastolic pressure
have not been affected. There are as yet few data on the interaction
of diltiazem and beta-blockers. Resting heart rate is usually unchanged
or slightly reduced by diltiazem.
Intravenous diltiazem in doses of 20 mg prolongs AH conduction
time and AV node functional and effective refractory periods approxi-
mately 20%. In a study involving single oral doses of 300 mg of
CARDIZEM in six normal volunteers, the average maximum PR
prolongation was 14% with no instances of greater ttian first-degree
AV block Diltiazem associatea prolongation of the AH interval is not
more pronounced in patients with first-degree heart block In patients
with sick sinus syndrome, diltiazem significantly prolongs sinus
cycle length (up to 50% in some cases).
Chronic oral administration of CARDIZEM in doses of up to 240
mg/day has resulted in small increases in PR interval, but has not
usually produced abnormal prolongation. There were, however, three
instances of second-degree AV block and one instance of third-
degree AV block in a group of 959 chronically treated patients.
Pharmacokinetics and MetaDolism. Diltiazem is absorbed
from the tablet formulation to about 80% of a reference capsule and
is subject to an extensive first-pass effect, giving an absolute
bioavailability (compared to intravenous dosing) of about 40%. CARDIZEM
undergoes extensive hepatic metabolism in which 2% to 4% of the
unchanged drug appears in the urine In vitro binding studies show
CARDIZEM is 70% to 80% bound to plasma proteins Competitive
ligand binding studies have also shown CARDIZEM binding is not
altered by therapeutic concentrations of digoxin, hydrochlorothiazide,
phenylbutazone, propranolol, salicylic acid, or warfarin. Single oral
doses of 30 to 120 mg of CARDIZEM result in detectable plasma
levels within 30 to 60 minutes and peak plasma levels two to three
hours after drug administration The plasma elimination half-life
following single or multiple drug administration is approximately 3.5
hours Desacetyl diltiazem is also present in the plasma at levels of
10% to 20% of the parent drug and is 25% to 50% as potent a
coronary vasodilator as diltiazem. Therapeutic blood levels of
CARDIZEM appear to be in the range of 50 to 200 ng/ml. There is a
departure from dose-linearity when single doses above 60 mg are
given; a 120-mg dose gave blood levels three times that of the 60-mg
dose. There is no information about the effect of renal or hepatic
impairment on excretion or metabolism of diltiazem.
INDICATIONS AND USAGE
1 Angina Pectoris Due to Coronary Aitery Spasm. CARDIZEM
is indicated in the treatment of angina pectoris due to coronary
artery spasm. CARDIZEM has been shown effective in the
treatment of spontaneous coronary artery spasm presenting as
Prinzmetal's variant angina (resting angina with ST-segment
elevation occurring during attacks).
2 Chronic Stable Angina (Classic Effort-Associated Angina).
CARDIZEM is indicated in the management of chronic stable
angina. CARDIZEM has been effective in controlled trials in
reducing angina frequency and increasing exercise tolerance.
There are no controlled studies of the effectiveness of the concomi-
tant use of diltiazem and beta-blockers or of the safety of this
combination in patients with impaired ventricular function or conduc-
tion abnormalities.
CONTRAINDICATIONS
CARDIZEM is contraindicated in (1) patients with sick sinus
syndrome except in the presence of a functioning ventricular pacemaker,
(2) patients with second- or third-degree AV block except in the
presence of a functioning ventricular pacemaker, and (3) patients
with hypotension (less than 90 mm Hg systolic).
WARNINGS
1. Cardiac Conduction. CARDIZEM prolongs AV node refrac-
tory periods without significantly prolonging sinus node recov-
ery time, except in patients with sick sinus syndrome This
effect may rarely result in abnormally slow heart rates (particularly
in patients with sick sinus syndrome) or second- or third-degree
AV block (six of 1243 patients for 0.48%). Concomitant use of
diltiazem with beta-blockers or digitalis may result in additive
effects on caidiac conduction. A patient with Prinzmetal’s
angina developed periods of asystole (2 to 5 seconds) after a
single dose of 60 mg of diltiazem.
2. Congestive Heart Failure. Although diltiazem has a negative
inotropic effect in isolated animal tissue preparations, hemodynamic
studies in humans with normal ventricular function have not
shown a reduction in cardiac index nor consistent negative
effects on contractility (dp/dt). Experience with the use of
CARDIZEM alone or in combination with beta-blockers in patients
with impaired ventricular function is very limited Caution should
be exercised when using the drug in such patients
3 Hypotension. Decreases in blood pressure associated with
CARDIZEM therapy may occasionally result in symptomatic
hypotension.
4 Acute Hepatic Injury. In rare instances, patients receiving
CARDIZEM have exhibited reversible acute hepatic injury as
evidenced by moderate to extreme elevations of liver enzymes.
(See PRECAUTIONS and ADVERSE REACTIONS.)
PRECAUTIONS
General. CARDIZEM (diltiazem hydrochloride) is extensively metab-
olized by the liver and excreted by the kidneys and in bile. As with any
new drug given over prolonged periods, laboratory parameters should
be monitored at regular intervals. The drug should be used with
caution in patients with impaired renal or hepatic function. In sub-
acute and chronic dog and rat studies designed to produce toxicity,
high doses of diltiazem were associated with hepatic damage. In
special subacute hepatic studies, oral doses of 125 mg/kg and
higher in rats were associated with histological changes in the liver
which were reversible when the drug was discontinued. In dogs,
doses of 20 mg/kg were also associated with hepatic changes;
however, these changes were reversible with continued dosing.
Drug Interaction. Pharmacologic studies indicate that there
may be additive effects in prolonging AV conduction when using
beta-blockers or digitalis concomitantly with CARDIZEM. (See
WARNINGS).
Controlled and uncontrolled domestic studies suggest that con-
comitant use of CARDIZEM and beta-blockers or digitalis is usually
well tolerated Available data are not sufficient, however, to predict
the effects of concomitant treatment, particularly in patients with left
ventricular dysfunction or cardiac conduction abnormalities. In healthy
volunteers, diltiazem has been shown to increase serum digoxin
levels up to 20%.
Carcinogenesis, Mutagenesis, Impairment of Fertility. A
24-month study in rats and a 21 -month study in mice showed no
evidence of carcinogenicity. There was also no mutagenic response
in in vitro bacterial tests. No intrinsic effect on fertility was observed
in rats.
Pregnancy. Category C. Reproduction studies have been con-
ducted in mice, rats, and rabbits. Administration of doses ranging
from five to ten times greater (on a mg/kg basis) than the daily
recommended therapeutic dose has resulted in embryo and fetal
lethality. These doses, in some studies, have been reported to cause
skeletal abnormalities In the perinatal/postnatal studies, there was
some reduction in early individual pup weights and survival rates.
There was an increased incidence of stillbirths at doses of 20 times
the human dose or greater.
There are no well-controlled studies in pregnant women; therefore,
use CARDIZEM in pregnant women only if the potential benefit
justifies the potential risk to the fetus.
Nursing Mothers. It is not known whether this drug is excreted
in human milk. Because many drugs are excreted in human milk,
exercise caution when CARDIZEM is administered to a nursing
woman it the drug's benefits are thought to outweigh its potential
risks in this situation.
Pediatric Use. Safety and effectiveness in children have not
been established.
ADVERSE REACTIONS
Serious adverse reactions have been rare in studies carried out to
date, but it should be recognized that patients with impaired ventricu-
lar function and cardiac conduction abnormalities have usually been
excluded.
In domestic placebo-controlled trials, the incidence of adverse
reactions reported during CARDIZEM therapy was not greater than
that reported during placebo therapy.
The following represent occurrences observed in clinical studies
which can be at least reasonably associated with the pharmacology
of calcium influx inhibition In many cases, the relationship to
CARDIZEM has not been established. The most common occurrences,
as well as their frequency of presentation, are: edema (2.4%),
headache (2.1%), nausea (1.9%), dizziness (1.5%), i
asthenia (1.2%), AV block (1.1%). In addition, the folic g
were reported infrequently (less than 1%) with the order u
tion corresponding to the relative frequency of occurre
Cardiovascular:
Nervous System;
Gastrointestinal:
Dermatologic:
Other:
Flushing, arrhythmia, hypotensitj
dia, palpitations, congestive h, i
syncope.
Paresthesia, nervousness, sat
tremor, insomnia, hallucinations,; y
Constipation, dyspepsia, diarrhc«
mild elevations of alkaline phosph t
SGPT, and LDH
Pruritus, petechiae, urticaria, pho ir
Polyuria, nocturia.
The following additional experiences have been not
A patient with Prinzmetal's angina experiencing
vasospastic angina developed periods of transient a
asystole approximately five hours after receiving a t
dose of CARDIZEM
The following postmarketing events have been re g
quently in patients receiving CARDIZEM erythema mu
kopenia; and extreme elevations of alkaline phosph;
SGPT, LDH, and CPK. However, a definitive cause and el
these events and CARDIZEM therapy is yet to be esta
OVERDOSAGE OR EXAGGERATED RESPO i
Overdosage experience with oral diltiazem has I
Single oral doses of 300 mg of CARDIZEM have been v
by healthy volunteers. In the event of overdosage or
response, appropriate supportive measures should be
addition to gastric lavage The following measures may b
Bradycardia
High-Degree AV
Block
Cardiac Failure
Hypotension
Administer atropine (0.60 to 1.0
is no response to vagal blockadi
isoproterenol cautiously.
Treat as for bradycardia above,
degree AV block should be trea
diac pacing.
Administer inotropic agents (is
dopamine, or dobutamine) and di
Vasopressors (eg. dopamine or
bitartrate).
Actual treatment and dosage should depend on the s
clinical situation and the ludgment and experience olt
physician.
The oral/LD50’s in mice and rats range from 415 tr
and from 560 to 810 mg/kg, respectively. The intraven
these species were 60 and 38 mg/kg, respectively. Thi
dogs is considered to be in excess of 50 mg/kg, while
seen in monkeys at 360 mg/kg The toxic dose in man !
but blood levels in excess of 800 ng/ml have not bee
with toxicity.
DOSAGE AND ADMINISTRATION
Exertional Angina Pectoris Due to Atheroscli
nary Artery Disease or Angina Pectoris at Rest I
nary Aitery Spasm. Dosage must be adjusted to e,
needs. Starting with 30 mg four times daily, before r
bedtime, dosage should be increased gradually (givr
doses three or four times daily) at one- to two-day ii
optimum response is obtained Although individual i
respond to any dosage level, the average optimum c
appears to be 180 to 240 mg/day. There are no available
ing dosage requirements in patients with impaired ren:
function. If the drug must be used in such patients, titrat!
carried out with particular caution.
Concomitant Uso With Other Antianginal Agoi
1 Sublingual NTG may be taken as required to
anginal attacks during CARDIZEM therapy.
2. Prophylactic Nitrate Therapy -CARDIZEM n
coadministered with short- and long-acting nitrat
ouaummioiGi uu vvii.ii oiiuii auu ivjuy aomiy miiui
have been no controlled studies to evaluate thi
effectiveness of this combination.
3 Beta-blockers. (See WARNINGS and PRECAUTIC
HOW SUPPLIED
Cardizem 30-mg tablets are supplied in bottles i
0088-1771-47) and in Unit Dose Identification Paks
0088-1771-49). Each green tablet is engraved with M7
side and 1771 engraved on the other. CARDIZEM 6i
tablets are supplied in bottles of 100 (NDC 0088-1772-4
Dose Identification Paks of 100 (NDC 0088-1772-49)
tablet is engraved with MARION on one side and 1772
Is1!
Another patient benefit product from
PHARMACEUTICAL DIVISION
MARION
LABORATORIES, INC
KANSAS CITY, MISSOURI 64137
\ortic and Mitral Valve
REPLACEMENT: PART 2*
Philip Olivieri, m.d., and John Kosns, m.d., new Brunswick**
The results of surgical management compared to medical
management of the valvular lesions are presented. The
hemodynamic consequences of surgery and the validity of
noninvasive guidelines for timing surgical intervention are
discussed. Special situations involving the repair of native valves
and the replacement of valve prostheses are reviewed.
I
ii
he value of valve replacement
Kj clearly has been established in
A acute aortic and mitral regurgi-
I nt lesions and in chronic valvular lesions when the
|*.tient is symptomatic. However, the need for and tim-
|g of surgical intervention in chronic valvular disease
| asymptomatic or minimally symptomatic patients
i controversial. Rahimtoola has cautioned that the
uks of early valve replacement (operative mortality,
rioperative myocardial damage, questionable long-
rm prosthetic performance, and influence on
yocardial function) should be weighed carefully
fainst the possible symptomatic relief and increased
i rvival resulting from a successful operation.4 De-
late detailed attempts to create rational guidelines for
I rgical intervention in these patients, the decision to
i change “native valve disease for prosthetic valve dis-
ise” remains to a large extent a matter of clinical
dgment.56
DRTIC STENOSIS
It is useful to separate operative or inhospital mor-
lllity from long-term mortality in assessing the benefit
i any valvular surgery. In general, operative mortality
i 5 percent or greater for single and 10 percent or
eater for double valve replacement.31 Aortic valve re-
acement usually is thought to have a more favorable
ig-term prognosis than mitral valve replacement
though some authors dispute this.2332 The early re-
)L. 81— NUMBER 12— DECEMBER 1984
suits of aortic valve replacement were poor due to high
operative mortality. Rotman et al. reported a series of
39 patients with aortic stenosis who underwent 43
procedures (36 replacements and 6 valvulotomies)
with an operative mortality of 31 percent.15 Improve-
ments in surgical technique such as cold cardioplegia
with potassium arrest, postsurgical management with
pulmonary arterial balloon-flotation catheters and
afterload reducing drugs, and valve prostheses dra-
matically have changed the figures. The 7 percent oper-
ative mortality in a recent study by Schwarz et al. is
typical and the 3.5 percent mortality cited by Cobbs
et al. is not uncommon.17-33
The results of several surgical series are presented
in Table 1. Surgical therapy clearly is superior to medi-
cal therapy in the presence of significant aortic
stenosis. Schwarz et al. reported 87 percent 3-year
survival by life-table analysis in a 1 25-patient operative
group versus 2 1 percent 3-year survival in a 19-patient
nonoperative group. The data of Schwarz et al. are
compared to composite data for the natural history of
the disease in Figure 1.
The indications for surgery in aortic stenosis are
*Part 1 appeared in the previous issue of The Journal, MSNJ.
**From the Division of Cardiovascular Diseases, UMDNJ-
Rutgers Medical School. Correspondence may be addressed
to Dr. Kostis, UMDNJ-Rutgers Medical School, CN 19. New
Brunswick, NJ 08903.
1055
TABLE 1
Rotman et al.
1971 15
Munoz et al.
197523
Smith et al.
197834
Carabello et al.
198043
Schwarz et al.
198217
Bonchek et al.
197446
Munoz et al.
197523
Ward and Hancock
197549
Results of Surgical Intervention
Aortic Stenosis
Series of 39 patients with aortic
stenosis, underwent 43
procedures (37 replacements
and 6 valvulotomies) with oper-
ative mortality 31 percent. Series
of 24 patients with stenosis/
regurgitation, underwent 26
procedures (23 replacements
and 3 valvulotomies) with oper-
ative mortality 25 percent.
Series of 47 patients with all
types of aortic valve disease
underwent aortic valve replace-
ment with operative mortality 27
percent and 70 percent 5-year
survival.
Series of 10 patients with severe
aortic stenosis and congestive
heart failure underwent valve re-
placement with operative mor-
tality 21 percent and 74 ± 10
percent actuarially predicted 3-
year + 5-year survival.
Series of 14 patients with severe
aortic stenosis and congestive
heart failure underwent valve re-
placement with operative mor-
tality 21 percent. Group I (10 of
1 1 with improvement): afterload
mismatch. Group II (1 of 1 1 with
no improvement + 3 operative
fatalities): depressed contractili-
ty-
Series of 125 surgical patients
with operative mortality 7 per-
cent and actuarially predicted 87
percent 3-year survival versus 19
medically treated patients with
21 percent survival.
Mitral Stenosis
Series of 150 patients with all
types of mitral valve disease
underwent mitral valve replace-
ment with operative mortality 2
percent and actuarially predicted
85 percent 5-year survival (40 of
150 with pure mitral stenosis).
Series of 118 patients with
mitral stenosis who underwent
open mitral commissurotomy
with operative mortality of 5 per-
cent. Series of 45 patients with
all types of mitral valve disease
who underwent valve replace-
ment with operative mortality 24
percent and 60 percent 5-year
survival.
Series of 27 patients with severe
mitral valve disease and
pulmonary hypertension under-
went mitral valve replacement
with 56 percent 5-year survival.
Group of 21 similar patients
managed medically had 10 per-
cent 5-year survival.
Hammermeister et al. Series of 249 patients with all
197830 types of mitral valve disease: 74
percent 5-year survival in
surgical group v 62 percent
survival in medical group. Group
of 45 patients with mitral
stenosis/regurgitation and 85
percent 5-year survival in group
of 22 medically managed pa-
tients.
Series of 545 patients with all
types of mitral valve disease
(stenosis 160, regurgitation 76,
and stenosis/regurgitation 309)
underwent mitral valve replace-
ment with 7 percent operative
mortality. Increased cardiothor-
acic ratio, left atrial size, or poor
hemodynamics prognostic.
Series of 202 patients with
mitral stenosis underwent open
mitral commissurotomy with op-
erative mortality 1.7 percent and
actuarially predicted 92 percent :
10-year survival.
Rutledge et al. Series of 303 patients with
198244 mitral stenosis underwent closed
mitral commissurotomy between
1954 and 1980 with an operative
mortality of 2 percent and actu-
arially predicted survivals of 95
percent at 5 years, 82 percent at
10 years, and 70 percent at 15
years. Subgroup of 54 patients
underwent valve replacement at
mean 9.6 years with operative
mortality of 13 percent and actu-
arially predicted 95 percent 5-
year and 74 percent 10-year
survivals.
Aortic Regurgitation
Gross et al.
1981 45
Dalby et al.
1 98 1 50
Rotman et al. Series of 30 patients with aortic
1971 15 regurgitation underwent 31
procedures (30 replacements
and 1 homograft) with operative
mortality 16 percent.
Heniy et al. I. Series of 50 symptomatic pa-
tients with 49 of 50 good
echocardiograms: 100 percent
(49 of 49) had left ventricular
dilatation, 29 percent (14 of 49)
had fractional shortening less
than 25 percent. Operative mor-
tality 6 percent. Late mortality 16
percent at 5 to 43 months; 8 of
continued
1056
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 1
Results of Surgical Intervention
49 with congestive heart failure.
Overall 43-month survival 77
percent. High-risk group (left
ventricular end-systolic diameter
above 55 mm, fractional
shortening below 25 percent) ac-
counted for 69 percent (9 of 13)
early + late mortality.
II. Series of 37 symptomatic pa-
tients with serial echocardio-
grams and mean followup of 34
months; 38 percent (14 of 37)
subsequently operated v 62 per-
cent (23 of 37) nonoperated (re-
mained asymptomatic).
Greves et al. Series of 45 patients with severe
198151 isolated aortic regurgitation
underwent valve replacement
with 4.4 percent operative mor-
tality; actuarially predicted 85
percent 5-year survival in 39 pa-
tients.
Kumpuris et al. Group A (postaortic valve re-
198257 placement normalization of left
ventricular function) with no
congestive heart failure or death.
Group B (postsurgical pro-
gression with 43 percent failure
and 29 percent mortality.
Series of symptomatic patients
with 85 percent 2-year and 63
percent 4-year survival. Opera-
tive morality 6 percent. High-risk
group contained low-risk sub-
group with preserved exercise ca-
pacity.
Surgical series with operative
mortality 7 percent and actu-
arially predicted 86 percent 5-
year survival v 87 percent 5-year
survival in medical cohort.
Mitral Regurgitation
Hammermeister et al. Series of 61 surgical patients
with 70 percent 5-year survival v
54 percent 5-year survival among
36 medically managed patients.
Phillips et al. Series of 105 patients with
mitral regurgitation underwent
valve replacement with 4 percent
operative mortality and 82 per-
cent actuarially predicted 5-year
survival. Only age above 60 years
or preoperative ejection fraction
less than 40 percent predicted
decreased 5-year survival.
Bonow et al.
198254
Schwarz et al.
198217
ummarized in Table 2. The decision to recommend
urgeiy in symptomatic patients in order to prolong
fe and to provide relief is straightforward. Prompt
peration is indicated even in those with severe con-
gestive heart failure or ejection fraction less than 20
Percent.3435 Age should not be a barrier to surgical
ntervention since benefit has been demonstrated even
la those greater than 70 years.36 Surgery in
symptomatic patients depends upon hemodynamic
tatus: surgery is indicated to decrease the risk of
udden death in the presence of a transvalvular gra-
lient greater than 50 mm/Hg and/or a valve area less
han 0.4 em2/m2 body surface area
Aortic valvulotomy rarely is possible in the adult
•opulation. Calcification of the aortic valve uniformly
3 present in adult aortic stenosis rendering
alvulotomy technically impossible without the crea-
ion of unacceptable aortic regurgitation. Accordingly,
he procedure of choice is replacement of the aortic
alve with a mechanical or bioprosthesis.
A controversy recently has arisen concerning the
leed for preoperative cardiac catheterization in pa-
tents undergoing valve replacement. St. John Sutton
[t al. and Brandenburg have suggested that cardiac
atheterization can be avoided in selected patients by
finical assessment and echocardiography.3738 Hakki et
1, O’Rourke, and Rahimtoola among others have pres-
nted detailed arguments stressing the need for
atheterization in the great majority of patients.31'41
Catheterization is required to determine the severity
4 the valvular lesion, to detect hidden associated
alvular disease, to definitively assess the degree of left
entricular dysfunction, and to evaluate the coronary
arteries. It seems prudent, at the present time, to con-
tinue the practice of preoperative cardiac catheteriza-
tion and coronary arteriography in all candidates for
valvular surgery.
Significant coronary arterial stenosis should be
bypassed at the same surgery which corrects the
valvular lesions. Combined valve and coronary artery
bypass surgery can be performed with a similar opera-
tive risk and late results as valve replacement alone.42
The left ventricular response to the pressure over-
load imposed by chronic aortic stenosis has been re-
viewed by Ross.35 Following an initial period of relative
left ventricular decompensation, concentration hyper-
trophy develops with a return to normal cardiac out-
put. Hyperfunction is evidenced by the leftward shift
of the pressure versus ventricular volume curve (Fig-
ure 2). However, the relation of wall stress to ven-
tricular diameter remains linear, demonstrating nor-
mal contractility. With decreasing contractility, this
relation is shifted downward and to the right. Follow-
ing successful valve replacement, the hvpertrophy re-
gresses and the left ventricular function either re-
mains normal or returns to normal within six months.
Ross concludes, “Mechanical overload per se rather
than irreversible depressed myocardial contractility
primarily is responsible for reduced left ventricular
function preoperatively in many patients, although in
a few, depressed contractility is clearly important."35
This concept is supported by the report of Carabello
et al. who described 14 patients with critical aortic
stenosis (valve area less than 0.4 cm2/m2) and con-
gestive heart failure submitted to valve replacement.43
There were 3 operative deaths (operative mortality 21
/OL. 81— NUMBER 12— DECEMBER 1984
1057
TABLE 2
Symptomatic:
Asymptomatic:
Symptomatic:
Asymptomatic:
Symptomatic:
Asymptomatic:
Indications for Valvular Surgery
Aortic Stenosis
Surgery recommended
Surgery recommended if:
a. Transvalvular gradient
greater than 50 mm/Hg and/or
b. Valve area less than 0.4
cm2/m2 body surface area
Advanced age no barrier to sur-
geiy
Mitral Stenosis
Surgery recommended
Surgery recommended if:
a Special circumstances such
as systemic embolization
b. Evidence of progressive
pulmonary hypertension
Aortic Regurgitation
Surgery recommended
Surgery recommended if:
a. M-mode echocardiographic
left ventricular end-systolic
diameter greater than 55 mm; or
b. M-mode echocardiographic
fractional shortening less than
25 percent and invasive study
confirms left ventricular dys-
function
The noninvasive criteria do not
apply to a small subset of pa-
tients in whom exercise capacity
is preserved.
Mitral Regurgitation
Surgery not recommended if
symptoms can be satisfactorily
controlled by standard medical
therapy. Disease not necessarily
progressive.
Surgery recommended if there is
evidence of progressive left ven-
tricular dysfunction and de-
terioration.
Surgery not recommended if
condition remains stable.
Surgery recommended if:
a. M-mode echocardiographic
left ventricular end-diastolic
diameter greater than 80 mm; or
b. M-mode echocardiographic
left ventricular end-systolic
diameter greater than 50 mm; or
c. M-mode echocardiographic
fractional shortening less than
30 percent;
d. M-mode echocardiographic
ejection fraction less than 55
percent: and invasive study con-
firms left ventricular dys-
function.
Symptomatic:
Asymptomatic:
t
percent) and 1 1 survivors. Ten of the survivors who
showed substantial improvement comprised Group I.
A linear relation was found between the ejection frac-
tion and left ventricular wall stress in Group I consis-
tent with afterload mismatch. The 3 operative fatalities
and 1 unimproved survivor comprised Group II. A
lowered ejection fraction for a given left ventricular
wall stress was found in Group II, consistent with de-
creased contractility. Thus, the concept of afterload
mismatch (inappropriate hypertrophy for the imposed
afterload) can help to explain the beneficial effect of
surgeiy in most patients.
MITRAL STENOSIS
The first surgical therapy in valvular heart disease
was mitral valvulotomy for mitral stenosis. Rowe et al.
in their classic study of the natural history of mitral
stenosis included the early data from Harkens group
showing the benefits of that procedure.20 Mitral com-
missurotomy continues to be the ideal “first proce-
dure” in surgical candidates with suitable valve
pathology (noncalcified, mobile leaflets). While open
mitral commissurotomy currently is the procedure of
choice among most surgeons, closed mitral com-
missurotomy equally is safe and remains useful in
experienced hands. Rutledge et al. reported a series of
303 patients who underwent closed mitral com-
missurotomy for acquired, isolated mitral stenosis be-
tween 1954 and 1980 with an operative mortality of
Years
Figure 1 — Aortic stenosis: Survival data for medical vers’
surgical management.
2 percent.44 Gross et al. reported a series of 202 p
tients who underwent open mitral commissurotorr'
between 1967 and 1978 with an operative mortality (.
1.7 percent.45
Those patients whose valves are not suitable fc;
commissurotomy or in whom commissurotomy he;
failed must undergo mitral valve replacement. Thi
procedure carries a higher operative mortality than tf
simpler commissurotomy. Kirklin and Pacifico cite
surgical series reviewed by Kouchoukos with a hosp
tal mortality of 5 percent for pure mitral stenosis
Boncheck reported a series of 150 patients (includin
40 patients with mitral stenosis) who underwent elec
1058
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
I
£
*• E
Volume (cc)
Figure 2— Pressure versus ventricular volume in valvular
aeart disease.
Medical management composite data
Rapaport (7)
Rowe et al. (20)
Surgical management:
Rutledge et al (44)
Years
Figure 3 — Mitral stenosis: Survival data for medical versus
surgical managment.
ive mitral valve replacement with only 2 percent oper-
ative mortality.46
The results of several surgical series are presented
n Table 1. Munoz et al. demonstrated the superiority
)f surgical therapy in mitral stenosis.23 They found an
35 percent 5-year survival in 1 18 patients undergoing
)pen mitral commissurotomy with an operative mor-
ality of 5 percent. The 5-year survival in a medically
reated group of 58 patients with mitral stenosis was
15 percent. The report of Rutledge et al. particularly
s useful because it showed that an initial or even
•epeat mitral commissurotomy does not prejudice the
-esults of later mitral valve replacement. The actu-
irially predicted 5-, 1 0-. and 1 5-year survival in the 303
jatients were 95 percent, 82 percent, and 70 percent,
-espectively. Fifty-four patients (18 percent) subse-
quently underwent mitral valve replacement at a mean
)f 9.6 years. The indications were residual stenosis
vith or without mild regurgitation in 33 patients (61
iercent), restenosis in 15 (28 percent), and moderate-
o-severe mitral regurgitation in 6 (11 percent). The
iperative mortality was 13 percent and the actuarially
predicted 5- and 10-year survivals were 95 percent and
74 percent, respectively. The data of Rutledge et al. for
nitral valve replacement are compared to composite
lata for the natural history of the disease in
dgure 3.
The indications for surgery in mitral stenosis are
summarized in Table 2. Surgery is recommended in
symptomatic patients in order to improve functional
status and provide symptomatic relief. Thus, patients
n New York Heart Association classes III and IV are
surgical candidates. Asymptomatic (class I) patients
ire not ordinarily surgical candidates except in special
circumstances such as following an episode of system-
c embolization. The class II patient presents a thera-
peutic dilemma Close followup is indicated and a high
ndex of suspicion for pulmonary hypertension should
)e maintained.
As noted, mitral commissurotomy (either open or
closed) is the procedure of choice in suitable patients,
rhose with residual stenosis or restenosis may under-
go a second commissurotomy with beneficial results
ilthough Rutledge et al. found a positive correlation
)etween repeat commissurotomy and subsequent
nitral valve replacement. Insertion of a prosthetic de-
vice can be performed with a low operative mortality
ind good long-term results, especially on an elective
>asis when class IV patients or patients with severe
pulmonary hypertension are avoided by early surgery.
Patients aged 30 years or younger with severe symp-
toms, with physical signs of isolated severe mitral
stenosis, and appropriate noninvasive finding are
among the small group of patients that may be ex-
cluded from preoperative cardiac catheterization.40
Although stroke volume and cardiac output are re-
duced in the presence of mitral stenosis, the function
of the left ventricle is fairly well preserved (Figure 2).
Unsuspected deterioration of the left ventricular func-
tion does not occur. Flessas and Ryan have reported
that patients with mitral stenosis demonstrate a nor-
mal chronotropic and pressor response to isometric
exercise.47 Wroblewski et al. have reported that the
right ventricle performs normally in patients with
moderate pulmonaiy hypertension, maintaining nor-
mal size and ejection fraction.48
Following successful surgery, substantial reduction
in left atrial and pulmonary pressures should occur.
Patients in whom surgery has been delayed until the
development of irreversible pulmonary hypertension
are at great risk. The series of Ward and Hancock is
instructive: 27 patients with severe pulmonary hyper-
tension and mitral valve disease underwent valve re-
placement with a 56 percent 5-year survival.49 A simi-
lar group of 21 patients treated medically had a 10
percent 5-year survival. Thus, pulmonary hypertension
should be considered an indication for surgery even
though the surgical risk is high since the nonsurgical
prognosis is dismal. This concept is supported by the
report of Dalby et al., who studied preoperative factors
affecting the outcome of isolated mitral valve replace-
ment.50 They found increased operative mortality in
patients with a large cardiothoracic ratio, a large left
atrium, and “poor hemodynamics." Poor hemody-
namics were defined as combinations of cardiac index
less than 1 .5 liters/min/m2, systolic pulmonary arterial
pressure greater than 100 mm/Hg, pulmonary
vascular resistance greater than or equal to 10 units,
or left ventricular end-diastolic pressure of 20 mm/Hg
or greater. However, they also found that the long-tenn
prognosis in those patients was no different from pa-
tients without the preoperative abnormalities. Clearly,
there is a need for meticulous perioperative care in the
compromised patients in order to reap the long-term
benefits of surgery.
AORTIC REGURGITATION
The regurgitant lesions of the aortic and mitral
/OL. 81— NUMBER 12— DECEMBER 1984
1059
AORTIC REGURGITATION SURVIVAL DATA FOR MEDICAL
VERSUS SURGICAL MANAGEMENT
valves impose a volume overload on the left ventricle.
However, the loading conditions are such that chronic
compensation is possible and each lesion therefore is
characterized by long latency. During the latent
periods, irreversible myocardial damage can occur and
it is this fact which is responsible for the therapeutic
dilemma in timing surgical intervention. The current
operative mortality is an important factor in the de-
cision to recommend surgeiy. A high operative risk
would tend to postpone the decision to undergo sur-
gery whereas a low risk would allow the patient to
obtain the benefits of earlier intervention.
As noted in the discussion of aortic stenosis, the
early results of aortic valve replacement were poor due
to high operative mortality. Rotman et al. reported a
series of 30 patients with aortic regurgitation who
underwent 31 procedures (30 replacements and 1
homograft) with an operative mortality of 16 percent.15
Later studies reflect not only the improvements cited
in the discussion of aortic stenosis, but also an in-
creased understanding of the pathophysiology of re-
gurgitant lesions. Greves et al. recently reported a
series of 45 patients who underwent aortic valve re-
placement for severe isolated aortic regurgitation be-
tween 1973 and 1979 with an operative mortality of
4.4 percent.51
The results of several surgical series are presented
in Table 1. Schwarz et al. reported 86 percent 5-year
survival by life- table analysis in a 127-patient operative
group versus 87 percent 5-year survival in a 13-patient
nonoperative group.17 They concluded, "Aortic valve
replacement does not change long-term survival in pa-
tients with aortic regurgitation, although those with
left ventricular dysfunction tended to live longer.” The
data of Schwarz et al. are compared to composite data
for the natural history of the disease in Figure 4.
In March 1980, a two-part prospective study by
Henry et al. entitled, "Observations on the Optimum
Time for Operative Intervention for Aortic Regurgi-
tation,” appeared in Circulation.52 Part I presented the
results of aortic valve replacement in 50 symptomatic
patients. The operative mortality was 6 percent and the
overall survival at 43 months was 77 percent. Forty-
nine patients had good quality echocardiograms and
formed the basis for the study. They found 100 percent
of the patients had left ventricular dilatation and 29
percent had fractional shortening less than 25 percent.
A high-risk group of 13 patients with left ventricular
end-systolic diameter greater than 55 mm and a frac-
tional shortening less than 25 percent was identified.
A 69 percent mortality (9 of 13 patients, combined
early and late deaths) occurred in this group. Part II
presented the results of 37 asymptomatic patients
with serial echocardiograms and a mean followup of
34 months. Fourteen patients (38 percent) developed
symptoms and went to surgery: the “subsequently op-
erated" group. Twenty-three patients (62 percent) re-
mained asymptomatic: the “nonoperated" group. The
left ventricular end-systolic diameter was 53.0 mm in
the subsequently operated group versus 44.3 mm in
the nonoperated group. The fractional shortening was
28.8 percent in the subsequently operated group ver-
sus 33.9 percent in the nonoperated group. The maxi-
mum rate of change of the left ventricular end-systolic
diameter was greater than 7 mm/year in only 1 patient.
Years
Figure 4— Aortic regurgitation: Survival data for medical vei
sus surgical management.
On the basis of these data, Heniy et al. proposed tha
a low-risk group with left ventricular end-systolic
diameter less than 50 mm could be followed safely a
yearly intervals with medical management.52 A high
risk group with left ventricular end-systolic diameteij
greater than 55 mm identified potential surgical can
didates for valve replacement requiring further study
In an editorial comment on the report of Henry et al.
O’Rourke and Crawford stressed the need for individ
ual assessment of the asymptomatic patient witt
severe aortic regurgitation and noted that the left ven
tricular end-systolic criteria were suggestive but no
proved.53
Bonow et al. reported that the low-risk group witf
aortic regurgitation defined by Heniy et al. hac
survival comparable to aortic stenosis patients witf
aortic valve replacement.54 They also identified a low
risk subgroup within the previously defined high-risl
group characterized by preserved exercise tolerana
(completion of Stage I of the National Institutes o
Health exercise protocol). Retained exercise capacity
did not correlate with either left ventricular end
systolic diameter or fractional shortening; it indepen
dently predicted a good postoperative prognosis.
The noninvasive guidelines proposed by Heniy et al
and Bonow et al. would appear to provide a rationa
basis for the appropriate timing for surgical inter
vention in aortic regurgitation. However, there are dif
ficulties in reproducing echocardiographic data
Rahimtoola cites a study by Turina et al. presented tc
the Working Group of the European Society o
Cardiology on Valvular Pros theses (Lyon, France; Octo
ber 1979) in which the results of Henry et al. were no
duplicated.41
The indications for surgery in aortic regurgitatior
are summarized in Table 2. The benefit of surgery ir
symptomatic patients for relief of symptoms ancj
prolongation of life is established. This is not the casi
in asymptomatic patients. They should be follower
closely utilizing the guidelines discussed above to an
ticipate the development of left ventricular dys
function. A small number of severely symptomatic pa
tients aged 30 years or younger with physical signs o
isolated severe chronic aortic regurgitation may b<
candidates for valve replacement without preoperativi
cardiac catheterization.40 However, the great majorit;
of symptomatic patients and all asymptomatic pa
tients should not undergo valve replacement withou
invasive studies.
1060
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
MITRAL REGURGITATION: SURVIVAL DATA FOR MEDICAL
VERSUS SURGICAL MANAGEMENT
Medical management, composite data
Rapaport (7)
Hammermeister et al. (30)
Surgical management
Phillips et al. (58)
Med.
<lgure 5— Mitral regurgitation: Survival data for medical ver-
;us surgical management.
It may be possible on rare occasions to repair the
ortic valve, especially in patients in whom regurgi-
ation is due to aneurysmal dilatation of the annulus
nd aortic root. In most cases, however, aortic valve
splacement is the procedure of choice. Reparative
rocedures have a tendency to deteriorate in the high
ressure and stress aortic position.
Having discussed aortic valve replacement in both
ortic stenosis and regurgitation, it is appropriate to
riefly review the data on replacement of dysfunctional
ortic prosthetic devices. Rossiter et al. reported 109
ortic valve reoperations with an operative mortailty
f 14 percent (15 of 109) and a late mortality of 25
ercent (23 of 94). 55 They found that preoperative
ardiac functional status and the nature of the
athology mandating valve replacement were the prin-
ipal determinants of both early and late mortality,
atients with prosthetic endocarditis or stenosis con-
tituted higher-risk subpopulations. Cohn et al. re-
orted 27 patients who underwent repeat surgeiy (8
)r endocarditis, 10 for primaiy valve dysfunction, and
for perivalvular leak) with an operative mortality of
5 percent (4 of 27) compared with 5.2 percent for
aitial aortic valve replacement.56 They concluded that
le inhospital risk for replacement of a prosthetic valve
ras not different from that of primary replacement
nless the patient deteriorated to class IV and required
mergency surgery.
The left ventricular response to the volume overload
nposed by chronic aortic regurgitation has been re-
iewed by Ross.35 It is characterized by the develop-
lent of eccentric left ventricular hypertrophy. The left
entricle can maintain a large ejection fraction without
large increase in the left ventricular end-diastolic
ressure due to the gradual increase in left ventricular
iastolic compliance, the reduced afterload due to
hronic peripheral vasodilatation, and the develop-
lent of appropriate ventricular hypertrophy. The
iastolic pressure-volume relation shifts to the right
ugure 2). When myocardial contractility decreases,
he end-systolic volume-wall stress relation shifts
ownward to the right. At that time, irreversible
lyocardial damage is present. Following successful
urgery prior to the onset of irreversible damage, Kum-
uris et al. found complete normalization of end-
ystolic dimension and of mean- and end-systolic wall
tresses with persistence of a normal shortening frac-
ion.57 Their study supported the observations ol
Henry et al. and reinforced the need for surgical inter-
vention prior to the onset of left ventricular deteriora-
tion.
MITRAL REGURGITATION
In comparison with the data accumulated for aortic
valve replacement in aortic regurgitation, there is a
paucity of comparable surgical data for mitral replace-
ment in mitral regurgitation. This is due in part to the
long latent period which characterizes the natural his-
tory of the disease. Also, early operative mortality fig-
ures were even less favorable than those for aortic
regurgitation. Recently, improved surgical techniques
and understanding of the pathophysiology of the
lesion have led to improved operative mortality. Phil-
lips et al. recently reported on 105 patients who under-
went mitral valve replacement for isolated mitral regur-
gitation between 1974 and 1979 with 4 percent in-
hospital deaths.58 In certain groups of patients it is
possible to repair rather than replace the mitral valve.
Kay et al. performed 133 consecutive mitral repairs for
pure mitral regurgitation with an operative mortality
of 5 percent.59 Carpentier et al. reported 10 years’ ex-
perience (1969 to 1978) with mitral reconstruction
with an inhospital mortality of 4.2 percent in patients
undergoing mitral repair only.60 In a preliminary re-
port, Boncheck had 1 operative death in 9 consecutive
patients undergoing insertion of a prosthetic ring.61
The results of several series are presented in Table
1. Hammermeister et al. found borderline improve-
ment over medical treatment with surgical treatment
for mitral regurgitation.30 They reported 70 percent 5-
year survival in a 61 -patient operative group versus 54
percent 5-year survival in the nonoperative group. Phil-
lips et al. had an actuarially predicted 82 percent 5-
year survival among 105 patients with mitral valve
replacement.58 Only age above 60 years and a
preoperative ejection fraction less than 40 percent
were found to correlate with a decreased 5-year
survival. The data of Phillips et al. are compared to
composite data for the natural histoiy of the disease
in Figure 5.
The indications for surgery in mitral regurgitation
are summarized in Table 2. Surgery is indicated in
symptomatic patients for symptomatic relief and pres-
ervation of left ventricular function when standard
medical management is not successful. It should be
emphasized again that mitral regurgitation is not
necessarily progressive and that moderate- to-severe
disease can be tolerated for many years without ill
effects. Bonehek recommends surgeiy for symptoms
alone in class III patients.32 Class II patients who are
content with their exercise capacity should be followed
with chest x-rays at six-month intervals. If cardiac
enlargement is noted, the chest x-ray should be re-
peated after three months. Progressive deterioration
requires further noninvasive and subsequent invasion
investigation. Ross recommends that cardiac
catheterization should be performed when
asymptomatic patients demonstrate left ventricular
end-diastolic diameter approaching 80 mm. end-
systolic diameter greater than 50 mm. fractional
shortening less them 30 percent, or ejection fraction
less than 55 percent.35
OL. 81— NUMBER 12— DECEMBER 1984
1061
Mitral valve repair utilizing a prosthetic ring often
is possible in nonrheumatic mitral regurgitation. This
procedure avoids the complications of prosthetic dys-
function and the need for chronic anticoagulation.
Furthermore, there is some preliminary data to sug-
gest that hemodynamic function is preserved to a
greater extent than with valve replacement.61 However,
mitral valve replacement remains the procedure of
choice in rheumatic mitral regurgitation as well as
those nonrheumatic cases where repair is not feasible.
The data on replacement of dysfunctional prosthetic
mitral valves suggest that this can be performed
without increased risk provided that the patient has
not deteriorated to class IV or requires an emergency
operation. Rossiter et al. reported 123 mitral reopera-
tions with an early mortality of 10 percent (12 of 123)
and a late mortality of 16 percent (18 of 1 1 1)55. Cohn
et al. reported 31 mitral replacements (6 for en-
docarditis, 19 for primary valve dysfunction, and 6 for
perivalvular leak) with 13 percent operative mortality
(4 of 13) compared with 6.4 percent for initial mitral
valve replacement.56
Unlike the increased left ventricular function com-
monly seen after aortic valve replacement for aortic
regurgitation, left ventricular function usually de-
teriorates further after mitral valve replacement for
mitral regurgitation. Patients with aortic regurgitation
tend to tolerate larger left ventricular end-systolic vol-
umes than those with mitral regurgitation. The expla-
nation for these findings has its roots in the mechan-
isms by which the left ventricle compensates for vol-
ume overloading in mitral regurgitation. This subject
has been reviewed in detail by Ross.57
There is an increase in left ventricular end-diastolic
compliance as the left ventricle enlarges. The increase
in end-diastolic volume and fiber length permit the left
ventricle to eject a large stroke volume via the Frank-
Starling mechanism (Figure 2). The left ventricle is
protected from developing increased end-diastolic
pressure or wall stress by the afterload reduction of the
valvular lesion: the regurgitant fraction is ejected into
the highly compliant, low pressure left atrium. Since
there is no isovolumetric contraction, the energy of
contraction can be expended in useful shortening
rather than the development of wall tension. There is
no decrease in coronary arteiy perfusion as sometimes
occurs in aortic regurgitation. As with aortic regurgi-
tation, the wall stress-volume relation shifts to the
right with the development of eccentric hypertrophy.
High stroke volume is maintained, mean wall stress
decreases, and the ejection fraction may be super-
normal. With decreased contractility, the curves shift
downward and to the right. When the low impedance
mitral leak is corrected surgically, the left ventricle
must suddenly deliver the full stroke volume in the
high-impedanee aorta The hidden myocardial damage
is suddenly unmasked and the ejection fraction de-
clines.
The effects of mitral valve replacement on the
anatomy and physiology of the left ventricle are still
incompletely understood. One study has shown that
myocyte disarray develops in papillary muscles re-
leased from their attachments after mitral valve re-
placement.62 This type of disarray was not thought to
occur postnatally. Another study identified transverse
midventricular disruption as the etiology of ver
tricular rupture following placement of a Hancoc
porcine prosthesis.33 The authors speculated that th
release of papillary muscles from their attachment
weakened the anatomical support of the mi(
ventricular region leading to subsequent ruptur
Twenty years ago, Lillehie et al. suggested that th
disruption of papillary muscles with surgery was r<
sponsible for the subsequent left ventricular enlarge
ment after mitral valve replacement.63 This hypothesi
was thought to have been disproved by Rastelli et a|
who studied canine mitral valve replacement with an
without preservation of chordae tendineae and foun ■
their presence or absence irrelevant to cardiac pei
formance.64 However, the preliminary report c
preserved hemodynamic function following mitr;
valve repair by Bonchek suggests that the canine e>
periments may not have been pertinent.61
REFERENCES
1. Harken DE, Soroff HS, Taylor WJ, Lafemine AA, Gupt
SK, Lunzer S: Partial and complete prostheses in aortic insu
ficiency. J Thorac Cardiovasc Surg 40:744-762, 1960.
2. Starr A Edwards ML: Mitral replacement: Clinical q
perience with a ball-valve prosthesis. Ann Surg 154:726-74(
1961.
3. Kirklin JW, Pacifico AD: Surgery for acquired valvule
heart disease. N Engl J Med 288:133-140; 194-199, 1973.
4. Rahimtoola SH: Early valve replacement for the presei
vation of function. Am J Cardiol 40:472-474, 1977.
5. Hammenneister KE: Chronic valvular disease i:
adults— when to operate. J Cardiovasc Med 6:632-655, 198:
6. Rahimtoola SH: Valve replacement should not be pei
formed in all asymptomatic patients with severe aortic ir
competence. J Thorac Cardiovasc Surg 79:163-172, 1980.
7. Rapaport E: Natural history of aortic and mitral valv
disease. Am J Cardiol 35:221-227, 1975.
8. Bogart DB, Murphy BL, Wong BYS, Pugh DM, Dunn M
Progression of aortic stenosis. Chest 76:391-396, 1979.
9. Cheitlin MD, Gertz EW, Brundage BH, Calson CJ, Quasi
JA Bode RS: Rate of progression of severity of valvular aorti
stenosis in the adult. Am Heart J 98:689-700, 1979.
10. Wagner S, Selzer A Patterns of progression of aorti ■
stenosis: A longitudinal hemodynamic study. Circulation
65:709-712, 1982.
1 1 . Ross J Jr, Braunwald E: Aortic stenosis. Ctrculatlor
38:suppl V:V6 1 -V67, 1968.
12. Bergeren J. Abelman WH, Vazquez-Milan H, Ellis LEi
Aortic stenosis-clinical manifestations and course of the dis
ease. Arch Intern Med 94:911-924, 1954.
13. Wood P: Aortic stenosis. Am J Cardiol 1:553-571, 1958,
14. Takeda J, Warren R Holzman D: Prognosis of aorti
stenosis. Arch Surg 87:931-963, 1963.
15. Rotman M, Morris JJ Jr„ Behar VS, Peter RH, Kong 'VI
Aortic valvular disease. Am J Med 51:241-257, 1971.
16. Frank S, Johnson A Ross J Jr.: Natural history oi
valvular aortic stenosis. Br Heart J 35:41-46, 1973.
17. Schwarz F, Bauman P, Manthey J, Hoffman M, Schula
G, Mehmel H, Schmitz W, Kubler W: The effect of aortic valvi
replacement on survival. Circulation 66:1105-1110, 1982.
18. Selzer A Cohn KE: Natural history of mitral stenosis
A review. Circulation 45:878-890, 1972.
19. Matthews MB, Medd WE, Gorlin R Aortic stenosis: fr
clinical study. Br Med J 2:759-763, 1955.
20. Rowe JC, Bland EF, Sprague HB, White PD: The course
of mitral stenosis without surgery: Ten- and 20-year per
spectives. Ann Intern Med 52:741-749, 1960.
21. Olesen KH: The natural history of 271 patients with]
mitral stenosis under medical treatment. Br Heart J
24:349-357, 1962.
22. Roy SB, Gopinath N: Mitral stenosis. Circulatior
38:suppl V:V68-V76, 1968.
23. Munoz S, Gallardo J, Diaz-Gorrin JR Medina O: In
fluence of surgery on the natural history of rheumatic mitra
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1062
id aortic valve disease. Am J Cardiol 35:234-242, 1975.
24. Goldschlager N, Pfeifer J, Cohn K, Popper R Selzer A:
le natural history of aortic regurgitation. Am J Med
1:577-588. 1973.
25. Spagnuolo M, Kloth H, Taranta A, Doyle E, Pasternack
Natural histoiy of aortic regurgitation. Circulation
1:368-380, 1971. '
26. Bland EF, Wheeler EO: Severe aortic regurgitation in
ung people. N Engl J Med 256:667-672, 1957.
27. Waller BF, Morrow AG, Maron BJ, Del Negro AA Kent
4, McGrath FJ, Wallace RB, McIntosh CL, Roberts WC:
iologv of clinically isolated, severe, chronic, pure mitral re-
irgitation: Analysis of 97 patients over 30 years of age
iving mitral valve replacement. Am Heart J 104:276-288,
182.
28. Selzer A, Katayama F: Mitral regurgitation: Clinical pat-
ms, pathophysiology, and natural histoiy. Medicine
:337-366, 1972.
29. Wilson MG, Lim WN: The natural history of rheumatic
•art disease in the third, fourth, and fifth decades of life.
rculation 16:700-712, 1957.
30. Hammermeister KE, Fisher L, Kennedy JW, Samuels S,
)dge HT: Prediction of late survival in patients with mitral
Ive disease from clinical, hemodynamic, and quantitative
igiographic variables. Circulation 57:341-349, 1978.
31. Rahimtoola SH: Valvular heart disease: A perspective.
Am Coll Cardiol 1:199-215.
32. Bonchek LI: Indications for surgery of the mitral valve,
n J Cardiol 46:155-158, 1980.
33. Cobbs BW Jr., Hatcher CR Jr., Craver JM, Jones EL,
■well CW: Transverse midventricular disruption after mitral
Ive replacement. Am Heart J 99:33-50, 1980.
34. Smith N, McAnulty JH, Rahimtoola SH: Severe aortic
mosis with impaired left ventricular function and clinical
•art failure: Results of valve replacement. Circulation
1:255-264, 1978.
35. Ross J Jr.: Left ventricular function and the timing of
rgical treatment in valvular heart disease. Ann Intern Med
r. 498-504, 1981.
36. Canepa-Anson R Emanuel RW: Elective aortic and
itral valve surgery in patients over 70 years of age. Br Heart
41:493-497, 1979.
37. St. John Sutton MG, St. John Sutton M, Oldershaw P,
icchetti R Paneth M, Lennox SC. Gibson DG:Valve replace-
ent without preoperative cardiac catheterization. N Engl J
ed 305:1233-1238, 1981.
38. Brandenburg RO: No more routine catheterization for
Ivular disease. N Engl J Med 305:1277-1278, 1981.
39. Hakki A, Kimbiris D, Iskandrian AS, Segal BL, Mintz
3, Benis CE: Angina pectoris and coronaiy artery disease
patients with severe aortic valvular disease. Am Heart J
10:441-449. 1980.
40. O'Rourke RA Preoperative cardiac catheterization: Its
■ed in most patients with valvular heart disease. JAMA
r8:745-750, 1982.
41. Rahimtoola SH: The need for cardiac catheterization
d angiography in valvular heart disease is not disproven.
m Intern Med 97:433-439, 1982.
42. Wisoff G, Fogel R Weisz D, Garvey J, Hamby R: Com-
ned valve and coronary artery surgery. Ann Thorac Surg
:440-443, 1979.
43. Carabello BA, Green LH, Grossman W, Cohn LH, Koster
s Collins JJ: Hemodynamic determinants of prognosis of
rtic valve replacement in critical aortic stenosis and ad-
nced congestive heart failure. Circulation 62:42-48, 1980.
44. Rutledge R McIntosh CL, Morrow AG, Picken CA Siwek
1, Zwischenberger JB, Schier JJ: Mitral valve replacement
:er closed mitral commissurotomy. Circulation 66:suppl
162-1166, 1982.
45. Gross RI, Cunningham JN Jr, Snively SL, Catinella FP,
ithan IM, Adams PX, Spencer FC: Long-term results of open
dical mitral commissurotomy: Ten-year followup study of
202 patients. Am J Cardiol 47:821-825, 1981.
46. Bonchek LI: Mitral valve replacement with cloth-cov-
ered composite-seat prostheses: The case for early operation.
J Thorac Cardiovasc Surg 67:93-109, 1974.
47. Flessas AP, Ryan TJ: Cardiovascular responses to
isometric exercise in patients with mitral stenosis. Arch In-
tern Med 142:1629-1633, 1982.
48. Wroblewski E, James F, Spann JF, Bove AA: Right ven-
tricular performance in mitral stenosis. Am J Cardiol
47:51-55, 1981.
49. Ward C, Hancock BW: Extreme pulmonary hyper-
tension caused by mitral valve disease: Natural histoiy and
results of surgery. Br Heart J 37:74-78, 1975.
50. Dalby AJ, Firth BG, Forman R Preoperative factors
affecting the outcome of isolated mitral valve replacement: A
10-year review. Am J Cardiol 47:826-834, 1981.
51. Greves J, Rahimtoola SH, McAnulty JH, DeMots H,
Clark DG, Greenberg B, Starr A: Preoperative criteria predic-
tive late survival following valve replacement for severe aortic
regurgitation. Am Heart J 101:300-308, 1981.
52. Henry WL, Bonow RO, Borer JS, Ware JH, Kent KM,
Redwood DR McIntosh CL, Morrow AG, Epstein SE: Observa-
tions on the optimum time for operative intervention for
aortic regurgitation. I. Evaluation of the results of aortic valve
replacement in symptomatic patients. Circulation
61:471-492, 1980.
53. O'Rourke RA, Crawford MH: Editorial: Timing of valve
replacement in patients with chronic aortic regurgitation.
Circulation 61:493-495, 1980.
54. Bonow RO, Rosing DR Kent KM, Epstein SE: Timing
of operation for chronic aortic regurgitation. Am J Cardiol
50:325-336, 1982.
55. Rossiter SJ, Miller DC, Stinson EB, Oyer PE, Reitz BA,
Shumway NE: Aortic and mitral prosthetic valve reoperations.
Arch Surg 114:1279-1283, 1979.
56. Cohn LH, Koster JK Jr, VandeVanter S, Collins JJ: The
inhospital risk of rereplacement of dysfunctional mitral and
aortic valves. Circulation 66:suppl 1:1 153-1 156, 1982.
57. Kumpuris AG, Quinones MA, Waggoner AD, Kanon DJ,
Nelson JG, Miller RR- Importance of preoperative hypertrophy,
wall stress, and end-systolic dimension as echocardiographic
predictors of normalization of left ventricular dilatation after
valve replacement in chronic aortic insufficiency. Am J
Cardiol 49:1091-1100, 1982.
58. Phillips HR Levine FH, Carter JE, Boucher CA. Osbak-
ken MD, Okada RD. Akins CW, Daggett WM, Buckley MJ,
Pohost GM: Mitral valve replacement for isolated mitral regur-
gitation: Analysis of clinical course and later postoperative left
ventricular ejection fraction. Am J Cardiol 48:647-654, 1981.
59. Kay JH, Zubiate P, Mendez AM, Carpena C, Watanabe
K, Magidson O: Mitral valve repair for patients with pure
mitral insufficiency. JAMA 236:1584-1586, 1976.
60. Carpentier A, Chauvaud S, Fabiani JN, Deloche A,
Relland J, Lessana A, d'Allaines CL, Blondeau PH, Piwnica A
Dubost CH: Reconstructive surgeiy of mitral valve in-
competence: Ten-year appraisal. J Thorac Cardiovasc Surg
79:338-348, 1980.
61. Bonchek LI: Correction of mitral valve disease without
valve replacement. Am Heart J 104:865-868, 1982.
62. Pirolo JS, Hutchins GM, Moore GW, Weisfeldt ML:
Myocyte disarray develops in papillary muscles released from
normal tension after mitral valve replacement. Circulation
66:841-846, 1982.
63. Lillehie CW, Levy MJ, Bonnabear RC: Mitral valve re-
placement with preservation of papillaiy muscles and
chordae tendineae. J Thorac Cardiovasc Surg 47:532-543,
1964.
64. Rastelli GC, Tsakiris AG, Fiye RL. Kirklin JW: Exercise
tolerance and hemodynamic studies after replacement of
canine mitral value with and without preservation of chordae
tendineae. Circulation 34:suppl 1:134-14 1 , 1967.
)L. 81— NUMBER 12— DECEMBER 1984
1063
When the Ayerst rep told
me
it costs about 454 a day,
I said you can stop right there
Most doctors are pleasantly surprised to learn that the average cost of
daily therapy with the world’s most widely used beta blocker is so little,
not much more than the cost of a daily newspaper.
When it’s INDERAL tablets (propranolol hydrochloride) you want for
your hypertension patients, remember to specify Dispense As Written
(DAW) or Do Not Substitute on your prescriptions. That way, you can
always be assured they’ll get INDERAL®.
Please see next page for brief summary of prescribing information.
“When the Ayerst rep told me
it costs about 45? a day,
I said you can stop right there.”
10 mg
SNDERAL
(PROPRANOLOL HCI)
20 mg 40 mg 60 mg 80 mg
90 mg*
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION , SEE PACKAGE CIRCULAR.)
INDERAL® (propranolol hydrochloride) Tablets
CLINICAL PHARMACOLOGY
The Beta-Blocker Heart Attack Trial (BHAT) was a National Heart, Lung and Blood Institute-
sponsored multicenter, randomized, double-blind placebo-controlled trial conducted in 31
U S centers (plus one in Canada) in 3,837 persons without history of severe congestive heart
failure or presence of recent heart failure; certain conduction defects; angina since infarction,
who had survived the acute phase of myocardial infarction. Propranolol was administered at
either 60 or 80 mg t.i.d. based on blood levels achieved during an initial trial of 40 mg t.i.d
Therapy with INDERAL. begun 5-21 days following infarction, was shown to reduce overall
mortality up to 39 months, the longest period of follow-up. This was primarily attributable to a
reduction in cardiovascular mortality. The protective effect of INDERAL was consistent
regardless of age, sex or site of infarction. Compared to placebo, total mortality was reduced
39% at 12 months and 26% over an average follow-up period of 25 months. The Norwegian
Multicenter Trial in which propranolol was administered at 40 mg q id gave overall results
which support the findings in the BHAT
Although the clinical trials used either t.i.d. or q i d. dosing, clinical, pharmacologic and
pharmacokinetic data provide a reasonable basis for concluding that b i d dosing with pro-
pranolol should be adequate in the treatment of post-infarction patients
CLINICAL In the BHAT, patients on INDERAL were prescribed either 180 mg/day (82% of
patients) or 240 mg/day (18% of patients). Patients were instructed to take the medication 3
times a day at mealtimes. This dosing schedule would result in an overnight dosing interval of
12 to 14 hours which is similar to the dosing interval for a b.i.d. regimen. In addition, blood
samples were drawn at various times and analyzed for propranolol. When the patients were
grouped into tertiles based on the blood levels observed and the mortality in the upper and
lower tertiles were compared, there was no evidence that blood levels affected mortality.
PHARMACOLOGIC: Studies in normal volunteers have shown that a 90 mg b.i d. regimen
maintains beta blockade at, or above, the minimum for 60 mg t.i d. dosing for 24 hours even
though differences occurred at two time intervals At 10-12 hours after the first dose of the day,
t.i.d dosing gave more beta blockade than b.i.d. dosing; at 20-24 hours the trend of the rela-
tionship was reversed These relationships were similar in direction to those observed for
plasma propranolol levels (see Pharmacokinetic).
PHARMACOKINETIC: A bioavailability study in normal volunteers showed that the blood
levels produced by 180 mg/day given b i d. are below those provided by the same daily dos-
age given t.i.d. at 10-12 hours after the first dose of the day but above those of at id. regimen
at 20-24 hours However, the blood levels produced by b i d. dosing were always equivalent
to or above the minimum for 1 1 d. dosing throughout the 24 hours In addition, the mean AUC
on the fourth day for the b i d regimen was about 17% greater than for the t.i.d. regimen (1,194
vs. 1,024 ng/mh hr)
CONTRAINDICATIONS
INDERAL is contraindicated in 1) cardiogenic shock. 2) sinus bradycardia and greater than
first degree block, 3) bronchial asthma, 4) congestive heart failure (see WARNINGS) unless
the failure is secondary to a tachyarrhythmia treatable with INDERAL
WARNINGS
CARDIAC FAILURE. Sympathetic stimulation may be a vital component supporting circula-
tory function in patients with congestive heart failure, and its inhibition by beta blockade may
precipitate more severe failure. Although beta blockers should be avoided in overt conges-
tive heart failure, if necessary they can be used with close follow-up in patients with a history
of failure who are well compensated and are receiving digitalis and diuretics. Beta-
adrenergic blocking agents do not abolish the inotropic action of digitalis on heart muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta blockers
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of heart
failure, the patient should be digitalized and/or treated with diuretics, and the response
observed closely, or INDERAL should be discontinued (gradually, if possible)
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation of
angina and, in some cases, myocardial infarction, following abrupt discontinuance of
INDERAL therapy. Therefore, when discontinuance of INDERAL is planned the dosage
should be gradually reduced over at least a few weeks and the patient should be cau-
tioned against interruption or cessation of therapy without the physician's advice. If
INDERAL therapy is interrupted and exacerbation of angina occurs, it usually is advis-
able to reinstitute INDERAL therapy and take other measures appropriate for the man-
agement of unstable angina pectoris. Since coronary artery disease may be
unrecognized, it may be prudent to follow the above advice in patients considered at risk
of having occult atherosclerotic heart disease who are given propranolol for other
indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphysema)— PATIENTS WITH
BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECEIVE BETA BLOCKERS.
INDERAL (propranolol hydrochloride) should be administered with caution since it may :•
bronchodilation produced by endogenous and exogenous catecholamine stimulation o b
receptors
MAJOR SURGERY: The necessity or desirability of withdrawal of beta-blocking therap
prior to major surgery is controversial. It should be noted, however, that the impaired abi :
the heart to respond to reflex adrenergic stimuli may augment the risks of general anestf ;
and surgical procedures.
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agonists l
its effects can be reversed by administration of such agents, e.g , dobutamineor isopro-
terenol However, such patients may be subject to protracted severe hypotension Diffici r
starting and maintaining the heartbeat has also been reported with beta blockers.
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the appea
ance of certain premonitory signs and symptoms (pulse rate and pressure changes) of ; s
hypoglycemia in labile insulin-dependent diabetes. In these patients, it may be more diff
to ad|ust the dosage of insulin
THYROTOXICOSIS, Beta blockade may mask certain clinical signs of hyperthyroidism Tt
fore, abrupt withdrawal of propranolol may be followed by an exacerbation of symptoms
hyperthyroidism, including thyroid storm Propranolol does not distort thyroid function te
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have bet
reported in which, after propranolol, the tachycardia was replaced by a severe bradycai
requiring a demand pacemaker In one.case this resulted after an initial dose of 5 mg
propranolol
PRECAUTIONS
General Propranolol should be used with caution in patients with impaired hepatic or re'
function INDERAL is not indicated for the treatment of hypertensive emergencies.
Beta-adrenoreceptor blockade can cause reduction of intraocular pressure Patients
should be told that INDERAL may interfere with the glaucoma screening test Withdraws ;
lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dise ,
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS: Patients receiving catecholamine-depleting drugs such as re |
pine should be closely observed if INDERAL is administered The added catecholamine I
blocking action may produce an excessive reduction of resting sympathetic nervous ac
which may result in hypotension, marked bradycardia, vertigo, syncopal attacks, or orth
static hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility: Long-term studies in animals hr
been conducted to evaluate toxic effects and carcinogenic potential. In 18-month studie
both rats and mice, employing doses up to 150 mg/kg/day, there was no evidence of sig
cant drug-induced toxicity There were no drug-related tumorigenic effects at any of the r
age levels. Reproductive studies in animals did not show any impairment of fertility lhal v
attributable to the drug
Pregnancy: Pregnancy Category C. INDERAL has been shown to be embryotoxic in a ilj
studies at doses about 10 times greater than the maximum recommended human dose
There are no adequate and well-controlled studies in pregnant women INDERAL shoi
be used during pregnancy only if the potential benefit justifies the potential risk to the fell
Nursing Mothers: INDERAL is excreted in human milk. Caution should be exercised wl| I
INDERAL is administered to a nursing woman
Pediatric Use1 Safety and effectiveness in children have not been established
ADVERSE REACTIONS
Most adverse effects have been mild and transient and have rarely required the withdrav '
therapy
Cardiovascular bradycardia; congestive heart failure, intensification of AV block, hyp'
sion, paresthesia of hands; thrombocytopenic purpura; arterial insufficiency usually of tf
Raynaud type.
Central Nervous System Lightheadedness; mental depression manifested by msomn
lassitude, weakness, fatigue, reversible mental depression progressing to catatonia; visi
disturbances; hallucinations; an acute reversible syndrome characterized by di sorientat
for time and place, short-term memory loss, emotional lability, slightly clouded sensoriurr
and decreased performance on neuropsychometrics
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diarrhea
constipation, mesenteric arterial thrombosis, ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined wilhacj
and sore throat, laryngospasm and respiratory distress.
Respiratory bronchospasm
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytopenic
purpura
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has been
reported
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male impo-
tence, and Peyronie's disease have been reported rarely. Oculomucocutaneous reactior
involving the skin, serous membranes and conjunctivae reported for a beta blocker (pra-
lol) have not been associated with propranolol
•The appearance of INDERAL tablets is a registered trademark of Ayerst Laboratories
9371/1184
i
AYERST LABORATORIES
New York, N.Y. 10017
1066
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Dialysis for End-Stage
Ienal Disease
John A. Walker, m.d., Robert Dodelson, m.d., Robert P. Eisinger, m.d. new Brunswick*
a consequence of end-stage renal disease , approximately
30,000 persons in the U.S. are dependent upon chronic dialysis. 1
These people receive care from non-nephrologists who may not
ie familiar entirely with the various dialytic modalities and
special needs of this population.
In 1854, Thomas Graham, a
Scottish chemist, used the term
dialysis (from the Greek dialyo,
separate) to describe the movement of various
utes across a semipermeable membrane.2 In 1918,
s concept was applied in vivo by Abel and his co-
rkers. They demonstrated the removal of nonprotein
rogen from the blood of a dog by passing the
imal’s anticoagulated blood through a series of
loidin tubes contained within a saline-filled glass
ket.3 Their device bears a striking resemblance to
: hollow-fiber dialyzers used today,
n 1926, the first human hemodialysis was per-
med in Germany by Haas. However, it was not until
15 that Kolff performed the first hemodialysis that
stained a patient suffering from acute renal failure
til recoveiy ensued.2
'echnical refinements of the hemodialysis tech-
[ue included the development of more efficient
lyzing membranes and incorporation of the mem-
ine into smaller containers. However, hemodialysis
named available only to those with reversible renal
ure as there was no way of gaining repeated, long-
m access to the circulation.
n 1960, Quinton and colleagues developed an ex-
nal arteriovenous shunt. Permanently placed into
: vasculature, this device allowed repeated access to
: circulation.4 Thus, the goal of chronic hemodialysis
the patient with irreversible renal failure was re-
alized. The cost of chronic hemodialysis remained a
formidable obstacle until 1972, when passage of Public
Law 92-603 extended Medicare coverage to all patients
with end-stage renal disease.5
PREDIALYSIS MANAGEMENT
Most individuals with advanced chronic renal fail-
ure, regardless of etiology, exhibit a steady decline in
renal function until dialysis is necessary to avoid or
reverse uremia The nature of this decline and mod-
ulating therapies are the subject of intensive investiga-
tion.6,7
It is not the purpose of this article to review the
management of the patient with chronic renal failure.
However, several important steps should be taken once
an individual with irreversible renal failure is iden-
tified. The patient should be informed of the eventual
need for dialysis and the various dialytic modalities
available. Consultation with a nephrologist may be de-
sirable at this time, since all modalities are not suitable
for all patients. In appropriate settings, renal trans-
plantation may be offered as the initial treatment for
end-stage renal disease or as an option to be con
*From the Department of Medicine. Division of Nephrology.
UMDNJ-Rutgers Medical School, New Brunswick Cor
respondence may be addressed to Dr. Walker, UMDNJ-
Rutgers Medical School, Academic Health Science Center. CN
19, New Brunswick, NJ 08903.
L 81— NUMBER 12— DECEMBER 1984
1067
sidered once dialysis is established. In any event, such
a presentation allows decisions to be made in a rela-
tively unhurried fashion. Delaying a discussion of
dialysis until the patient is nearly uremic or overtly
uremic is of no benefit.
If hemodialysis is deemed appropriate, vascular ac-
cess should be established prior to initiating chronic
hemodialysis. The arteriovenous fistula, developed by
Brescia and Cimino in the mid-1960s, presently is the
preferred technique.8 A subcutaneous arteriovenous
(AV) anastomosis is created surgically, typically in the
nondominant upper extremity. In a few weeks to
months, the diverted arterial flow “arterializes” the ve-
nous system, creating a network of hypertrophied ves-
sels that can withstand multiple needle punctures and
provide optimal blood flow. If the native vasculature
cannot support an AV fistula (as may be the case in
diabetic or elderly individuals), a synthetic or bovine
graft may be anastomosed into the extremity’s blood
vessels. In either case, the access should be established
by an experienced vascular surgeon.
The existence of a healed, mature vascular access
greatly facilitates the initiation of chronic hemodial-
ysis and avoids the need for femoral vessel cannulation
or subclavian vein catheterization. Since the AV fistula
is a high-flow, high-pressure system, it must not be
subjected to sphygmomanometiy or routine venipunc-
ture.
When to initiate chronic dialysis depends upon a
combination of clinical and laboratory data9 Few
would argue that dialysis ought to begin when the
creatinine clearance (Ccr) falls below 5 ml/min, even
if the patient feels reasonably well. Uremic symptoms
are not reversed readily by dialysis and there is little
to be gained by temporizing for another month or two
at the risk of developing uremic bleeding, hyper-
kalemia pericarditis, or neuropathy. At Ccrs of 10 to
5 ml/min, the patient should be monitored for any
vague constitutional symptoms such as anorexia
weakness, or pruritus which may be manifestations of
uremia Such individuals often note a remarkable im-
provement in their sense of well-being after initiation
of dialysis. Ely this time, the primary physician and the
patient should have established a relationship with a
nephrologist who will be able to assist in deciding
when to begin dialysis.
For a more extensive discussion of the management
of the predialysis patient, the reader is referred to re-
cent reviews.1011
HEMODIALYSIS— PRINCIPLES
Dialysis can accomplish two objectives: 1) the re-
moval of excess solutes that accumulate in the body
as a result of their diminished excretion; and 2) the
removal of water that accumulates as a consequence
of the end-stage kidney's inability to generate free
water. Although the kidney’s role as a hormonal organ
is well established, resultant derangements from end-
stage renal disease are not directly ameliorated by
chronic dialysis.
Regardless of the hardware employed, the basic prin-
ciples of hemodialysis are the same. Blood is
withdrawn into an extracorporeal circuit where, via a
roller pump, it is passed across a synthetic, semi-
permeable membrane. This membrane separates the
blood from the dialysate, a solution with a compositii|
that, with certain exceptions, approximates plasr
water. A typical dialysate contains sodium, chlori<;
magnesium, and calcium in concentrations equal to
slightly less than that of normal plasma Potassiu
may be added to a concentration of 2 to 3 mEqj
Dextrose may be added to prevent hypoglycemia a
facilitate water removal. Acetate replaces bicarbone
as a buffer, since the latter would precipitate calciu
and magnesium in the commercially prepared sol
tions. Recent data suggest acetate may have delete
ous effects on the cardiovascular system during heir
dialysis, and dialysis machines now are available tb
mix bicarbonate into a buffer-free dialysate just befc.
the solution reaches the membrane.12
The synthetic dialysis membrane commonly
manufactured from regenerated cellulose. None
lulosic membranes, e.g. polyacrylonitrile, also are ava-
able.13 These newer materials can effect grealj
clearances of larger molecules, theoretically an adva
tage if middle molecules are indeed responsible f
abnormalities that persist in spite of chror
hemodialysis. The membrane is packaged in a co
tainer that has inlet and outlet ports for both bloi
and dialysate. This unit is referred to as the dialyzi
Most present-day dialyzers utilize a membrane r
ranged to form either a bundle of hollow fibers wi
internal diameters of 200 to 300 /uM or a series
parallel plates. Both are enclosed within a rigid col
tainer and are noneompliant. This noncompliance pi
mits the removal of water from the plasma by applyiiji
negative hydrostatic pressure to the dialysate side
the membrane.
The dialysis machine delivers blood and dialysate
the dialyzer at appropriate rates. Once the blood a l
dialysate come into contact with the membrarl
solutes begin moving across the membrane down thf
concentration gradients. In this fashion, undesirat1
solutes such as urea and creatinine are removed fro
the plasma
Most dialysis machines in use today are single-pas
proportioning systems. That is, the dialysate makes
single pass across the membrane, countercurrent
blood flow, and then is discarded. The average dialysa
flow rate is 500 ml/min. To avoid the need for storir
the 120 liters of dialysate required for a four-hoi
treatment, the machine proportions a dialysate coi
centrate into treated tap water at a 1:35 ratio. T1
machine monitors the dialysate for prop**
temperature and electrical conductivity (the latter is
measurement of proper proportioning function). T!
machine also measures pressures within the e:
tracorporeal blood circuit and monitors for air leal
within the blood lines. These features are incorporate
in a compact machine with automatic monitoring an
shut-off functions, thus making home hemodialysis
practical option for many patients.
Another type of dialysis machine regenerates use
dialysate by passing it through a cartridge containir
urease, ion exchange resins, and activated charcof
The regenerated dialysate then can be passed throug
the dialyzer again. This system requires only 5.5 litei
of dialysate and thus is not dependent upon a continij
ous water supply. EEowever, dialysis with this systei
results in changes in serum chemistries that are som<
1068
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSE
hat different from those seen with single-pass sys-
ms. It is not in widespread use.14
The removal of excess water is accomplished as
ater is separated from the protein and cellular ele-
ents of the blood, a process known as ultrafiltration,
jring hemodialysis, ultrafiltration is achieved largely
r applying appropriate hydrostatic pressure to one
de of the membrane. In single-pass systems utilizing
mcompliant dialyzers, the application of negative
rdrostatic pressure to the dialysate circuit results in
■t fluid removal from the plasma water. How much
lid must be removed is determined by the difference
■tween a patient’s weight at the beginning of a
alysis treatment and that individual’s diy weight,
le dry weight is the weight at which the patient is
nically euvolemic and usually normotensive. By
lowing the ultrafiltration properties of the particular
alyzer being used, the dialysis staff can adjust the
achine to ultrafilter the volume of water necessaiy
achieve diy weight at the treatment’s conclusion.
Ultrafiltration also may be effected by using osmotic
ther than hydrostatic forces. This principle is em-
Dyed in peritoneal dialysis.
3E DIALYSIS REGIMEN
The usual hemodialysis “prescription” consists of 4
5 hours of dialysis administered thrice weekly. For
ost patients, this leads to resolution of many of the
emic symptoms that may have been present prior to
itiation of dialysis. Twelve to 15 hours of
■modialysis weekly also maintain urea nitrogen levels
ithin an acceptable range. Unfortunately, chronic
“modialysis does not resolve all features of end-stage
nal disease. Some degree of anemia persists in most
itients. Moreover, problems such as osteodystrophy
id neuropathy may progress in spite of regular
alysis. That these problems may ameliorate after a
iccessful renal transplant is evidence that the
alysis regimen does not completely replace normal
nal function.1516
Chronic dialysis affords in-
creased longevity to the ma-
jority of patients with end-
stage renal disease.
rhe excretion of various solutes by the kidney com-
Dnly is expressed in terms of clearance. The method
which the kidney clears solutes from the plasma is
ite different from that seen with dialyzing mem-
anes. This is evident when the clearances of two
lutes of different molecular size are compared. The
:arances of creatinine (113 daltons) and inulin
200 daltons) by the normal kidney are nearly iden-
al (approximately 100 ml/min). Yet, when dialyzer
trances of these substances are measured, the
:arance of inulin is much less than that of creatinine
ml/min v 90 ml/min, respectively). Thus, the
alyzer clears small molecules such as urea and
;atinine rapidly, and clearances of these solutes may
improved by increasing blood flow rates across the
;mbrane. However, dialyzer clearances of molecules
larger than 500 daltons are low. The clearance of
molecules in this middle range (500 to 5,000 daltons)
may be improved somewhat by increasing the duration
of dialysis and/or increasing the surface area of the
dialyzing membrane.17
These observations are explained by the fact that
solute clearance across the dialyzing membrane is gov-
erned by the relatively small pore size of the membrane
and the varying sizes of plasma solutes. Small
molecules easily pass through the membrane pores;
larger molecules diffuse across the membrane with
greater difficulty as their molecular sizes increase. It
has been proposed that the persistence of some of the
complications of end-stage renal disease (anemia, neu-
ropathy, and osteodystrophy) in spite of regular
dialysis is due to an accumulation of these poorly
cleared middle molecules.18 A great deal of investigative
activity has not yet identified which middle molecules
might be uremic toxins.19 Dialysis regimens have been
modified in an effort to improve clearances of these
solutes. However, a recent national cooperative study
showed that when compared with patients whose BUN
was allowed to remain high (90 mg/dl), chronic
hemodialysis patients whose BUNs were kept low (50
mg/dl) required fewer hospitalizations regardless of
whether they received 9 or 13'/2 hours of dialysis week-
ly.20 These results tend to refute the middle molecule
hypothesis, which would have predicted a better out-
come for the patients who received longer treatments
regardless of urea levels.
Presently, therefore, dialysis regimens are designed
to maintain reasonable levels of measurable solutes
and an acceptable state of fluid balance. For most pa-
tients, 12 to 15 hours of dialysis weekly appear ade-
quate.
MEDICAL MANAGEMENT OF THE
DIALYSIS PATIENT
Nearly all patients receiving chronic hemodialysis
must adhere to certain dietaiy restrictions. It is dif-
ficult to ultrafilter large volumes in the course of a
four-hour dialysis treatment without precipitating
hypotension, syncope, or muscle cramps. Therefore,
fluid intake must be closely monitored and limited if
interdialytic fluid gains are excessive. Most patients
are placed on sodium and potassium restrictions as
well.
In contrast to the protein restriction often
prescribed for predialysis azotemic patients, chronic
hemodialysis patients are encouraged to consume a
high-quality protein diet (1 gm/kg/day). since regular
dialysis will maintain urea at acceptable levels. Un-
fortunately, this protein intake obligates a substantial
phosphate intake. High phosphate levels generally are
undesirable in the chronic hemodialysis patient, as
they perpetuate the vicious cycle of secondary hyper-
parathyroidism and resultant osteodystrophy.21 Ac-
cordingly, oral phosphate binders in the form of
aluminum hydroxide or aluminum carbonate are ad-
ministered. The constipation these agents may induce
makes patient compliance difficult. Stool softeners or
oral sorbitol may alleviate this problem, but oc-
casionally a tap water or soap-suds enema is necessaiy.
Under no circumstances should a dialysis patient re
)L. 81— NUMBER 12— DECEMBER 1984
1069
ceive a Fleet® enema or a magnesium-containing
cathartic. The phosphate and magnesium loads these
agents respectively contain clearly are dangerous to
the individual with end-stage renal disease. Most pa-
tients take a daily water-soluble vitamin and folate
supplement to replace dialysis losses.22
The excretion of many drugs and their metabolites
is dependent upon normal renal function.
Furthermore, some medications are removed efficient-
ly by hemodialysis. These factors must be taken into
account when prescribing medication for the chronic
hemodialysis patient. Failure to do so may result in
drug toxicity or subtherapeutic drug levels.23 Dosing
guidelines are available to aid the clinician in planning
appropriate medication regimens.24
A detailed discussion of the medical complications
associated with chronic hemodialysis is beyond the
scope of this article. However, we will briefly discuss
certain problems the non-nephrologist may encounter
in the chronic hemodialysis patient.
Often referred to as the Achilles’ heel of chronic
hemodialysis, the vascular access may be the site of
several complications.25 Both grafts and native fistulas
may become thrombosed or stenotic, resulting in
diminished blood flow through the access network.26
Such a complication may be heralded by loss of the
thrill over the fistula Prompt referral to a vascular
surgeon is indicated, as thrombectomy or revision of
the access will likely be necessaiy. As the vascular ac-
cess is a high-flow, turbulent system, antibiotic pro-
phylaxis is recommended for the chronic hemodialysis
patient scheduled to undergo dental, upper respir-
atory, genitourinary, or gastrointestinal procedures.27
The vascular access always should be considered a
source of an otherwise unexplained bacteremia even
when the access site clinically appears benign.
Staphylococci are common organisms in this setting,
and endocarditis may complicate the picture.28 Ap-
propriate antibiotic therapy alone may suffice when a
native fistula is the source of infection, but infected
synthetic or bovine grafts may have to be removed to
effect a cure.29
That cardiovascular complications are common in
the chronic hemodialysis population is not surprising,
since many of these patients have a history of
cardiovascular disease. Hypertension in the end-stage
renal disease population usually is due to fluid over-
load. Normotension is achieved with fluid and salt re-
striction along with progressive ultrafiltration to the
appropriate dry weight. However, a minority of patients
remain hypertensive despite euvolemia and will re-
quire antihypertensive medication. Increased pe-
ripheral vascular resistance secondary to hyper-
reninemia has been shown to be responsible for many
such cases.30 In the past, bilateral nephrectomy was
required to control blood pressure when pharma-
cologic therapy failed. The availability of newer agents
such as captopril and minoxidil now largely render
this procedure unnecessary.31 Indeed, the “end-stage”
kidney still may perform some degree of solute excre-
tion and hormonal, e.g. erythropoietin, production, so
preservation of renal parenchyma usually is desirable.
Hemodialysis may precipitate hypotension and ar-
rhythmias in patients with ischemic heart disease.
These problems may be aggravated if interdialytic fluid
gains are excessive. In these fragile patients, adequa- Lc
ultrafiltration rates may be achieved if the ultr
filtration is performed without concomitant dialysis
The anemia that accompanies end-stage renal disea:*
may exacerbate angina Such patients may requi
periodic red blood cell transfusions to avoid sympf
matic ischemia
Pericarditis commonly is not observed once regul
dialysis is well underway. However if, through a varie
of circumstances, a patient is relatively underdialyze:
pericarditis may be the first overt manifestation
uremia33 Patients receiving chronic hemodialysis m
be at increased risk for viral infections, which may 1
manifest as pericarditis.34
In spite of these problems, the presence
cardiovascular disease could not be considered a
absolute contraindication to hemodialysis. Many sue
patients tolerate chronic hemodialysis without undi
difficulty. It may be necessary to provide a trial
hemodialysis before recommending another modalit
The majority of chronic hemodialysis patien
exhibit a normocytic anemia While diminish^
erythropoietin production may play an etiologic rolj
erythropoietin levels have been noted to be normal <
even elevated in some patients.35 Impaired bone ma
row erythrogenesis and shortened red blood cr
survival are demonstrable in end-stage renal diseas
and these undoubtedly are important factors in tl
pathophysiology of the anemia36 Many patients tole
ate hematocrits of 20 to 30 percent surprisingly we
There usually is no need to administer blood tran
fusions unless a patient becomes symptomatic. TI
hematocrit often will increase once a patient is starte|i
on chronic hemodialysis.37 Furthermore, routir
transfusions may lead to iron overload and heme
siderosis.38 39 Patients may, however, develop iro
deficiency due to small but ongoing blood losses ir
curred with each treatment, since some red cells ii!
evitably are left behind in dialyzers and blood lines.;
Oral iron supplements therefore are given to most p;;
tients. Parenteral androgens often are helpful in mair
taining adequate hemoglobin levels.41 A number q
studies have shown improved renal transplant surviv;
in patients who received red cell transfusions prior tj
the transplantation.42 The reason for this is poorl
understood, but most transplant centers now rec
ommend that patients awaiting a cadaveric rem
transplant receive several units of packed red cell!
before surgery.43
Many chronic hemodialysis patients have
prolonged bleeding time due to a qualitative platele:
dysfunction. This may improve following dialysis.44 1
addition, administration of cryoprecipitate or ir
travenous desmopressin may temporarily correct thi
defect.45-46
Osteodystrophy remains a frustrating problem fo
patients and physicians. Chronic hemodialysis pa
tients may suffer from a variety of bone disorder?
including osteosclerosis, osteitis fibrosa cystica, ami
osteomalacia47 Attempts to suppress the high para
thyroid hormone (PTH) levels seen in many patient
by controlling serum phosphate and administerin,
oral calcium and vitamin D analogues may be onf|
partially successful. High PTH levels also have beei
incriminated as an etiologic factor in the anemia am
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1070
mropathy of end-stage renal disease.48-49 Para-
yroidectomy may be necessary in resistant cases.
?cently, a group of chronic hemodialysis patients has
>en described with osteomalacia increased bone
uminum content, myopathy, and normal PTH
/els.50 In these patients trials of chelation therapy
ith desferrioxamine to reduce aluminum stores pres-
itly are in progress.51
The chronic hemodialysis population is at increased
sk for infection. The cell-mediated immune response
depressed.52 This may in part explain the higher
eidence of hepatitis B and mycobacterial infections
|fen in these patients.5354 However, responses to im-
unization often are adequate.55 Therefore, adminis-
lation of pneumococcus, influenza, and, if hepatitis
'surface antibodies are not present, hepatitis B vac-
/ne is recommended.
Neurologic disorders may cause signfieant problems
the chronic hemodialysis patient. Uremic neu-
ipathies, both sensory and motor, may be arrested by
ironic hemodialysis but improvement usually is
|)ted only after a successful renal transplant.16
ncephalopathy may indicate a central nervous sys-
m infection, subdural hematoma or dialysis demen-
'a.56 The last is a syndrome peculiar to chronic
emodialysis patients, often accompanied by dys-
raxia, myoclonus, and a characteristic elec-
oeneephalogram. Aluminium has been implicated as
n etiologic factor, but the exact cause of this often
tal disorder remains unknown.57
Chronic hemodialysis also may be associated with
number of iatrogenic complications. Hemolysis may
:cur if dialysate water contains high levels of copper
■ chloramine.5859 Proper water treatment at the
ialysis unit usually will prevent this. Water-borne
acterial contaminants may cause febrile reactions.60
ecently, a review of liver biopsies obtained from CHD
jatients revealed areas of inflammation and fibrosis in
hich silicone particles were found. The silicone
resumably entered the circulation via spallation of
licone blood tubing by the dialysis machine’s roller
amp.61 Patients on chronic hemodialysis must be an-
icoagulated with heparin during each dialysis session
) prevent their blood from clotting within the dialyzer.
Ihis may increase the risk of bleeding if other
jathology is present (e.g. peptic ulcer disease).
ERITONEAL DIALYSIS
At present, only about 10 percent of the end-stage
■nal disease population is maintained on some form
(' chronic peritoneal dialysis; there is considerable
iterest in this increasingly popular modality.62
The concept of utilizing the peritoneum as a dialyz-
lg membrane dates back to the 1920s.63 However, it
as not until the 1970s that Moncrief and Popovich
leorized that adequate dialysis could be achieved by
sequentially instilling and draining two liter aliquots
f dialysate into and out of the peritoneal cavity five
mes daily.64 This concept has evolved into the tech-
ique of continuous ambulatory peritoneal dialysis
:apd).
When compared with artificial dialyzers, the peri-
rneum, in many respects, is less efficient. Peritoneal
earances of small molecules such as urea and
reatinine are substantially less than those achieved
with hemodialysis membranes.65 However, in CAPD
the dialysate is almost constantly in contact with the
peritoneum. Therefore, when calculated on a weekly
basis, small molecular clearances nearly are equivalent
in the two modalities. Furthermore, clearance of larger
molecules actually is better in CAPD than with chronic
hemodialysis. Nolph has explained these features with
a model of the peritoneal membrane that incorporates
a small number of large pores through which larger
molecules may easily pass.66
Ultrafiltration in CAPD is accomplished via osmotic,
rather than hydrostatic, forces. Peritoneal dialysate is
rendered hypertonic to plasma by adding dextrose.
Peritoneal instillation of this hypertonic solution
causes plasma water to move out of the vascular space
into the peritoneal cavity. This volume then is removed
when the dialysate is drained.
Infection in the form of peri-
tonitis remains the most
common complication of
CAPD .
The actual technique of CAPD is relatively simple. A
permanent, flexible catheter is placed surgically in the
peritoneal cavity. A short segment of this catheter re-
mains external, and is attached to a connecting tube.
At the end of the connecting tube is a spike connector.
The dialysate is supplied in plastic bags. Two liter
aliquots usually are employed. The spike connector is
inserted into the dialysate bag and dialysate is instilled
into the peritoneal cavity. When emptied, the bag and
connecting tube are rolled up and tucked under the
patient’s clothing. The dialysate is allowed to dwell in
the peritoneal cavity for approximately four hours. The
bag then is unrolled and the dialysate is allowed to
drain back into the bag. The bags are designed to
accommodate the extra volume removed by ultra-
filtration. When drainage is complete, the drained bag
is discarded and a bag of fresh dialysate attached to
the spike connection. The cycle then is repeated. The
exchange of bags must be performed using sterile tech-
nique. Three exchanges are performed during the day.
A fourth aliquot is instilled at bedtime and drained in
the morning. In this fashion, adequate biochemical
and volume control can be achieved.67
The exchange technique is taught to most patients,
who then are able to perform their own dialysis.
Although CAPD must be done daily, these patients are
freed from the logistic and temporal restrictions of
chronic hemodialysis. Patients who are employed must
perform one exchange at the workplace. Traveling no
longer is restricted, since the CAPD patient can pack
the necessary quantity of dialysate and supplies. The
exchanges can be performed wherever a small sterile
field can be set up.
CAPD thus is an appropriate modality for the end-
stage renal disease patient whose activities or employ-
ment would make adherence to a thrice weekly
hemodialysis schedule difficult. Patients with a trail
cardiovascular status also might be considered for
CAPD, where ultrafiltration rates are slower, thus ef-
fecting a gentler control of volume. Diabetics with cnd-
OL. 81— NUMBER 12— DECEMBER 1984
1071
stage renal disease may do well on CAPD. Regular in-
sulin added to the dialysate often results in improved
blood glucose control and dispenses with the need for
subcutaneous insulin injections. However, total in-
sulin requirements increase due to the added
carbohydrate load of the dialysate dextrose.68
A history of multiple abdominal surgical procedures
is a relative contraindication to CAPD. The presence
of adhesions or peritoneal scarring may impair the
efficacy of the dialysis. Abdominal ostomies usually are
a contraindication to CAPD due to the increased risk
of catheter infection, and abdominal or inguinal
hernias should be repaired prior to initiating CAPD.
Patients with a history of low back pain or lumbar disk
disease have reported worsening of their symptoms
with CAPD. CAPD may produce increased dyspnea in
those with severe chronic lung disease, presumably
due to the limitation of diaphragmatic mobility in-
duced by the instillation of the large dialysate vol-
umes.69 Finally, successful CAPD requires a motivated,
compliant patient who will perform the four daily ex-
changes using aseptic technique. If the patient is not
able to perform the exchanges, a family member may
be trained. However, in our opinion nonself-adminis-
tered CAPD is an arrangement that should be ap-
proached with caution.
Infection in the form of peritonitis remains the most
common complication of CAPD. Even in centers with
a large CAPD population and long-term experience,
infection rates average one to two episodes per patient
year 67
Infecting organisms presumbly gain entry to the
peritoneal cavity via the catheter lumen or the sub-
cutaneous tunnel through which the catheter courses
before entering the cavity. The vast majority of cases
are of bacterial origin with Staphylococcus aureus
and Staphylococcus epidermidis responsible for
about three-quarters of episodes. Gram-negative spe-
cies are the etiology in about 20 percent of cases. A
small number of infections are caused by mycobacteria
or fungi.70
Peritonitis associated with CAPD initially may mani-
fest only as clouding of the drained dialysate without
pain or fever. The presence of greater than 100 white
blood cells/mm3 in the drained dialysate is considered
evidence of peritonitis. Such uncomplicated cases can
be treated with the addition of antibiotics to the
dialysate and continuation of the CAPD schedule. A
cephalosporin and an aminoglycoside typically are em-
ployed, and the appropriate antibiotic continued when
the offending organism is identified. Patient technqiue
is reviewed carefully, as errors or omissions may have
precipitated the infection. Failure to eradicate the in-
fection or repeated episodes of peritonitis may necessi-
tate removal of the dialysis catheter and transfer to
hemodialysis.70
In-line bacterial filters now are available and
preliminary studies of these devices are encouraging.71
A device which uses ultraviolet radiation to sterilize
the spike connection recently was released for patient
use. These and other modifications in the CAPD tech-
nique may lessen the incidence of peritonitis in the
future.
Peritoneal dialysis may be administered in other
fashions. A cycling machine is available that automati-
cally performs several exchanges overnight while tf
patient sleeps. A two-liter dialysate volume dwells i'l
the abdomen during the day, and the patient agah
connects to the cycler when retiring. This techniqu
known as continuous cyclic peritoneal dialysis (CCPC
eliminates the need for a patient to interrupt dai ;
activities to perform dialysate exchanges. It remains lr
be seen whether this modality is intrinsically superir
to CAPD.
Peritoneal dialysis may be administered thrice weel t
ly, with hourly exchanges performed for 10 to 12 hour
This technique, known as intermittent peritone;
dialysis (IPD), usually is performed in a dialysis uni
It is typically reserved for the debilitated, often elder
individual who cannot receive other forms of per
toneal dialysis and who cannot tolerate chron;
hemodialysis. However, 30 to 40 hours of intermitter
peritoneal dialysis weekly may not provide sufficier
dialysis if residual renal function is very low.72 f
should not be considered for the otherwise health
end-stage renal disease patient.
It is difficult to compare peritoneal dialysis wit
hemodialysis. The majority of patients with end-stag
renal disease in this country receive chronij
hemodialysis, and patients previously relegated to per
toneal dialysis may constitute a different subgrou
with respect to cardiovascular disease, diabetej
mellitus, and other risk factors. Nevertheless, whe!
compared with chronic hemodialysis, CAPD ca
achieve comparable degrees of biochemical and flui
control.73 Whether CAPDs augmented clearance c
middle molecules results in improved morbidity is a,
yet an unproved expectation. A disturbing aspect
CAPD are retrospective studies showing a high drop
out rate. A study of European CAPD programs showe
a 51 percent drop-out rate at two years.62 It is hope
that better infection control will lead to an improve
ment of this phenomenon.
SURVIVAL WITH DIALYSIS
The risk of death among patients receiving dialysi
is about 20 percent per year. This figure must b
viewed in light of the fact that two-thirds of dialysf
patients in the United States are over 50 years old.7
Many of these individuals have significant extrarena
especially cardiovascular, diseases when beginning
dialysis therapy. It is not surprising then, that th<
majority of deaths in the end-stage renal disease popu
lation are of cardiovascular etiologies. Survival o
younger patients (less than 50 years old) receiving
dialysis is superior (90 percent at 1 year).74 There id
no doubt that chronic dialysis affords increased Ion
gevity to the majority of patients with end-stage rena
disease. Whether chronic dialysis sustains an ac
ceptable quality of life is a more difficult issue to ad
dress. A recent study analyzed the level of physica
activity and employment status of nearly 2,500 dialysf
patients. Sixty percent of nondiabetic patients wen'
capable of physical activity beyond that of self-care
This figure was only 23 percent for the diabetic group
Fifty-two percent of nondiabetic men were un
employed.75
Although these results may not be an accurate reflec
tion of the entire end-stage renal disease program, the}
do point out that dialysis, while capable of sustaining
1072
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
fe. cannot be expected to improve other significant
athology that may have led to renal disease in the first
lace. Nevertheless, chronic dialysis permits
lousands of individuals who would otherwise be dead
) lead useful and satisfying lives. That many patients
ow are receiving their second decade of chronic
ialysis is a significant testament to this remarkable
?chnology.76
EFERENCES
1. Luke R Renal replacement therapy. N Engl J Med
38: 1593- 1 595, 1983.
2. Drukker W: Haemodialysis: A historical review, in: Druk-
?r W, Parsons F, Maher J (eds): Replacement of Renal Func-
on by Dialysis. The Hague, Martinus Nijhoff, 1978, pp. 3-37.
3. Abel JJ, Rowntree LG, Turner BB: On the removal of
iffusable substances from the circulating blood of living
limals by dialysis. J Pharmacol Exp Ther 5:275-316, 1918.
4. Quinton W, Dillard D, Scribner B: Cannulation of blood
’ssels for prolonged hemodialysis. Trans Am Soc Artif Intern
rgans 6:104-1 13, 1960.
5. Blagg C: Cost of dialysis and transplantation, in: Fried-
an E fed): Strategy in Renal Failure. New York, NY, John
'iley & Sons, 1978, pp. 483-503.
6. Hostetter T, Brenner B: Glomerular adaptations to renal
juiy, in: Brenner B, Stein J (eds): Chronic Renal Failure.
?w York, NY, Churchill Livingstone, 1981, pp. 1-27.
7. Brenner B, Meyer T, Hostetter T: Dietary protein intake
id the progressive nature of kidney disease: The role of
mrodynamically mediated glomerular injury in the
ithogenesis of progressive glomerular sclerosis in aging,
nal ablation, and intrinsic renal disease. N Engl J Med
)7:652-659, 1982.
8. Brescia M, Cimino J, Appel K, Hurwich B: Chronic
;modialysis using venipuncture and a surgically created
teriovenous fistula N Engl J Med 275:1089-1092, 1966.
9. Friedman E: Pre-end-stage assessment of the azotemic
itient, in: Friedman E (ed): Strategy in Renal Failure. New
)rk, NY, John Wiley & Sons, 1978, p. 7-44.
10. Mitch W: Conservative management of chronic renal
ilure, in: Brenner B, Stein J (eds): Chronic Renal Failure.
;w York, NY, Churchill Livingstone, 1981, pp. 116-152.
11. Kurtzman N: Chronic renal failure: Metabolic and
inical consequences. Hosp Pract 17(8):107-122, 1982.
12. Samar R Bicarbonate and acetate in hemodialysis.
ontemporary Dialysis August 1981, pp. 10-23.
13. Funck-Brentano J-L, Man N: The polyacrylonitrile
embrane and the rhodial system: Their practical appli-
:tion, in: Drukker W, Parsons F, Maher J (eds): Replacement
Renal Function by Dialysis. The Hague, Martinus Nijhoff,
)78, pp. 125-134.
14. Drukker W, Parsons F, Gordon A: Practical application
dialysate regeneration: The Redy system, in: Drukker W,
irsons F, Maher J (eds): Replacement of Renal Function by
ialysis. The Hague, Martinus Nijhoff, 1978, pp. 244-258.
15. Cobum J, Slatopolsky E: Vitamin D, parathyroid
irmone, and renal osteodystrophy, in: Brenner B, Rector F
is): The Kidney. 2nd Edition. Philadelphia, PA, W.B.
lunders Co., 1981, pp. 2213-2305.
16. Bolton C, Baltzan M, Baltzan R Effects of renal trans-
antation on uremic neuropathy. N Engl J Med
14:1170-1175, 1971.
17. Babb A, Popovich R Christopher T, Scribner B: The
nesis of the square meter-hour hypothesis. Trans Am Soc
tif Intern Organs 17:81-91, 1971.
18. Navarro J, Contreras P, Touraine J, et al.: Are 'middle
oleeules’ responsible for toxic phenomena in chronic renal
ilure? Nephron 32:301-307, 1982.
19. Contreras P, Later R Navarro J, et al.: Molecules in the
iddle molecular weight range. Nephron 32:193-201, 1982.
20. Lowrie E, Laird N, Parker T, Sargent J: Effect of the
modialysis prescription on patient morbidity. N Engl J Med
>5:1176-1181, 1981.
21. Bricker N: On the pathogenesis of the uremic state. N
igl J Med 286:1093-1099, 1972.
22. Kopple J, Swendseid M: Vitamin nutrition in patients
undergoing maintenance hemodialysis. Kidney Int 7S79-
S84, 1975.
23. Muther R Bennett W: Drug metabolism in renal failure,
in: Brenner B, Stein J (eds): Chronic Renal Failure. New York
NY, Churchill Livingstone, 1981, pp. 287-323.
24. Bennett W, Aronoff G, Morrison G, et al.: Drug prescrib-
ing in renal failure: Dosing guidelines for adults. Am J Kid
Dis 3:155-193, 1983.
25. Kjellstrand C: The Achilles' heel of the hemodialysis
patient. Arch Intern Med 138:1063-1064, 1978.
26. Butt R Vascular concerns in preparing for end-stage
care, in: Friedman E (ed): Strategy in Renal Failure. New
York NY, John Wiley & Sons, 1978, pp. 187-208.
27. Durack D: Prophylaxis of infective endocarditis, in:
Mandell G, Douglas G, Bennett J (eds): Principles and Prac-
tice of Infectious Diseases. New York, NY, John Wiley & Sons
1979, pp. 701-710.
28. Dobkin J, Miller M, Steigbigel N: Septicemia in patients
on chronic hemodialysis. Ann Intern Med 88:28-33, 1978.
29. Cross A, Steigbigel R- Infective endocarditis and access
site infections in patients on hemodialysis. Med 55:453-466
1976.
30. Vertes V, Cangiano J, Berman L, Gould A: Hypertension
in end-stage renal disease. N Engl J Med 280:978-981, 1969.
31. Pettinger W, Mitchell H: Minoxidil — an alternative to
nephrectomy for refractory hypertension. N Engl J Med
289:167-171, 1973.
32. Shinaberger J, Brautbar N, Miller J, Gardner P: Suc-
cessful application of sequential hemofiltration followed by
diffusion dialysis with standard dialysis equipment. Trans
Am Soc Artif Intern Organs 24:677-681, 1978.
33. Leehey D. Daugirdas J, Ing T: Early drainage of peri-
cardial effusion in patients with dialysis pericarditis. Arch
Intern Med 143:1673-1675, 1983.
34. Osanloo E, Shalhoub R Cioffi R Parker R Viral peri-
carditis in patients receiving hemodialysis. Arch Intern Med
139:301-303, 1979.
35. Caro J, Brown S, Miller O, et al.: Eiythropoietin levels
in uremic nephric and anephric patients. J Lab Clin Med
93:449-458, 1979.
36. Ohno Y, Rege A, Fisher J, Barona J: Inhibitors of
erythroid colony-forming cells (CFU-E and BFU-E) in sera of
azotemic patients with anemia of renal disease. J Lab Clin
Med 92:916-923, 1978.
37. Radtke H, Frei U, Erbes P, et al.: Improving anemia by
hemodialysis: Effect on serum erythropoietin. Kidney Int
17:382-387, 1980.
38. Gokal R Millard P, Weatherall D, et al.: Iron metabolism
in haemodialysis patients. Quart J Med 48:369-391, 1979.
39. Ali M, Fayemi O, Rigolosi R et al.: Hemosiderosis in
hemodialysis patients. JAMA 244:343-345, 1980.
40. Longnecker R Goffinet J, Hendler E: Blood loss during
maintenance hemodialysis. Trans Amer Soc Artif Int Organs
20:135-141, 1974.
41. Hendler E, Goffinet J, Ross S, et al.: Controlled study
of androgen therapy in anemia of patients on maintenance
hemodialysis. N Engl J Med 291:1046-1051, 1974.
42. Opelz G, Terasaki P: Improvement of kidney-graft
survival with increased numbers of blood transfusions. N
Engl J Med 299:799-803, 1978.
43. Moore S: The enigma of blood transfusions and kidney
transplantation. Mayo Clin Proc 57:431-438, 1982.
44. Stewart J, Castaldi P: Uremic bleeding: A reversible
platelet defect corrected by dialysis. Quart J Med 36:409-423,
1967.
45. Janson P, Jubelirer S, Weinstein M, Deykin D: Treat-
ment of the bleeding tendency in uremia with cryoprecipitate.
N Engl J Med 303:1318-1322, 1980.
46. Mannucci P, Remuzzi G, Pusineri F, et al.: Deamino-8-
D-arginine vasopressin shortens the bleeding time in uremia
N Engl J Med 308:8-12, 1983.
47. Avioli L, Teitelbaum S: Renal osteodystrophy, in: Earley
L, Gottschalk C (eds): Strauss and Welt's Diseases of the
Kidney. 3rd Edition Boston, MA, Little, Brown & Co.. 1979,
pp. 307-370.
48. Potasman I, Better O: The role of secondary hyper-
parathyroidism in the anemia of chronic renal failure.
Nephron 33:229-231, 1983.
49. Avram M, Feinfeld D, Huatuco A: Search for the uremic
9L. 81— NUMBER 12— DECEMBER 1984
1073
toxin. N Engl J Med 298:1000-1003, 1978.
50. Hodsman A, Sherrard D, Wong E, et al.: Vitamin-D-
resistant osteomalacia in hemodialysis patients lacking sec-
ondary hyperparathyroidism. Ann Intern Med 94:629-637,
1981.
51. Brown D, Dawsom J, Ham K, Xipell J: Treatment of
dialysis osteomalacia with desferrioxamine. Lancet
11:343-345, 1982.
52. Goldblum S, Reed W: Host defenses and immunologic
alterations associated with chronic hemodialysis. Ann Intern
Med 93:597-613, 1980.
53. Szmuness W, Prince A, Grady G, et al.: Hepatitis B
infection. JAMA 227:901-906, 1974.
54. Lundin A, Adler A, Berlyne G, Friedman E: Tuberculosis
in patients undergoing maintenance dialysis. Am J Med
67:597-602, 1979.
55. Simberkoff M, Schiffman G, Katz L, et al.: Pneu-
mococcal capsular polysaccharide vaccination in adult
chronic hemodialysis patients. J Lab Clin Med 96:363-370,
1980.
56. Raskin N, Fishman R Neurologic disorders in renal
failure. N Engl J Med 294 (Part 1): 143- 148, 294 (Part
111:204-210, 1976.
57. Sideman S, Manor D: The dialysis dementia syndrome
and aluminum intoxication. Nephron 31:1-10, 1982.
58. Manzler A Schreiner A Copper-induced acute
hemolytic anemia Ann Intern Med 73:409-412, 1970.
59. Yawata Y, Howe R Jacob H: Abnormal red cell
metabolism causing hemolysis in uremia Ann Intern Med
79:362-367, 1973.
60. Hindman S, Favero M, Carson L, et al.: Pyrogenic reac-
tions during haemodialysis caused by extramural endotoxin.
Lancet 11:732-734, 1975.
61. Leong A Disney A Gove D: Spallation and migration
of silicone from blood-pump tubing in patients on
hemodialysis. N Engl J Med 306:135-140, 1982.
62. Nolph K Boen F, Farrell P, Pyle R Continuous am-
bulatory peritoneal dialysis in Australia Europe, and the
United States: 1981. Kidney Int 23:3-8, 1983.
63. Ganter G: Ueber die Beseitigung giftiger Stoffe aus dem
Blute durch Dialyse. Munch Med Wochenschr 70:1478-1481
1923.
64. Popovich R Moncrief J, Nolph K, et al.: Continuou
ambulatory peritoneal dialysis. Ann Intern Med 88:449-45(
1978.
65. Nolph K Popovich R Ghods A Twardowski Z: Determ
nants of low clearances of small solutes during peritonei
dialysis. Kidney Int 13:117-123, 1978.
66. Nolph K, Sorkin M: Continuous ambulatory peritonei
dialysis, in: Brenner B, Stein J (eds): Chronic Renal Failur
New York, NY, Churchill Livingstone, 1981, pp. 193-218.
67. Levey A Harrington J: Continuous peritoneal dialysi
for chronic renal failure. Med 61:330-338, 1982.
68. Rottembourg J, Shahat Y, Agrafiotis A et al.: Contini
ous ambulatory peritoneal dialysis in insulin-dependent di;
betic patients: A 40-month experience. Kidney Int 23:40-41
1983.
69. Twardowski Z, Prowant B, Nolph K et al.: High volum<
low frequency continuous ambulatory peritoneal dialysis
Kidney Int 23:64-70, 1983.
70. Vas S: Microbiologic aspects of chronic ambulator
peritoneal dialysis. Kidney Int 23:83-92, 1983.
71. Ash S, Horswell R Heeter E, Bloch R Effect of th
peridex® filter on peritonitis rates in a CAPD populatior
Peritoneal Dialysis Bulletin 3:89-93, 1983.
72. Ahmad S, Gallagher N, Shen F: Intermittent peritonet
dialysis: Status reassessed. Trans Am Soc Artif Intern Organ
25:86-89, 1979.
73. Nolph K Sorkin M, Rubin J, et al.: Continuous am
bulatory peritoneal dialysis: Three-year experience at on
center. Ann Intern Med 92:609-613, 1980.
74. Krakauer H, Grauman J, McMullan M, Creede C: Th
recent U.S. experience in the treatment of end-stage ren;
disease by dialysis and transplantation. N Engl J Mei
308:1558-1563, 1983.
75. Gutman R Stead W, Robinson R Physical activity ant
employment status of patients on maintenance dialysis. 1
Engl J Med 304:309-313, 1981.
76. Neff M, Eiser A Slifkin R et al.: Patients surviving 1(
years of hemodialysis. Am J Med 74:996-1004, 1983.
1074
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
New studies
uncover the
potassium effects oi
beta-2 blockade
Clinical pharmacology
data from the
New England Journal
of Medicine:
f...when normal young men are given infu-
sions of epinephrine at levels such as those
that circulate in patients with myocardial
infarction , their serum potassium concen-
trations fall by about 0.8 mmol per liter.
Hypokalemia is prevented by... beta-2
blockade."'
INDERAL
(propranolol HCI)
prevented beta-2
mediated hypokalemia
In a pharmacological study comparing
INDERAL with atenolol, 10 hypertensive
patients were infused with the nonselective
beta agonist, isoproterenol, which also
stimulates beta-2 mediated hypokalemia.
At doses high enough to overcome beta-1
mediated heart rate reductions, the hypo-
kalemia caused by isoproterenol was
blunted by INDERAL, but not by atenolol.2
INDERAL compared with atenolol:
change in plasma potassium after
beta-agonist infusion2
_L
J_
3.5
14
35 70
ng/kg ' min '
INDERAL tablets, 80 mg qid
Atenolol, 100 mg qd
No beta blockade
140 280 560
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Vincent et al, p 1122
Hil
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From the Lancet:
"Although both diuretics and adrenaline are
known to cause hypokalaemia, we believe
that this is the first demonstration that these
two factors can act in an additive manner.
Routine monitoring of serum potassium in
patients on thiazide diuretics may under-
estimate the risks of hypokalaemia.'
Epinephrine-induced
lypokalemi
:CG abnorr
la can cause
" 3
Epinephrine drives potassium into cells—
an effect that has been shown to be under
beta-2 receptor control4; thiazides promote
excretion of potassium. When these ac-
tions occur together, hypokalemia can
intensify significantly.3
ECG abnormalities
typical of other forms
of hypokalemia
In a study of the effects of epinephrine-
induced hypokalemia on the electro-
cardiogram, it was shown that levels of
plasma epinephrine similar to those
observed during myocardial infarction
can produce changes in ventricular re-
polarization, which are reflected in
T-wave flattening and QT prolonga-
tion in normal subjects.5
In clinical pharmacology studies of hyper-
tensive and normal patients, epinephrine-
induced hypokalemia was prevented by
beta-2 blockade.2 4
MM
Once-daily INDERAL LA
(propranolol HCI) for
smooth blood pressure
control without the
potassium problems
of diuretics
Patients with "uncomplicated" hyper-
tension may develop ventricular
arrhythmias in the presence of hypo-
kalemia.6 Once-daily INDERAL LA
maintains smooth blood pressure reduc-
tions without a negative effect on serum
potassium and provides patients with
broad cardiovascular benefits-all in
a convenient daily dose.
Like conventional INDERAL tablets,
INDERAL LA should not be used in the
presence of congestive heart failure, sinus
bradycardia, heart block greater than first
degree, and bronchial asthma.
And for lifetime
benefits in foundation
treatment of angina
Once-daily INDERAL LA provides 24-hour
control of angina symptoms-plus the
cardiovascular benefits of the world's lead-
ing beta blocker. And unlike calcium
channel blockers, INDERAL LA, alone or
with a nitrate, is recommended for first-line
treatment of stable angina.
Simply start new patients on 80 mg
INDERAL LA once daily. Dosage may
be increased to 1 60 mg once daily to
achieve maximal control.
■ _
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The appearance of
Please see la
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.( summary of, prescribing information
80 mg 120 mg 160 mg
INDERAL
inmmuxia TABLETS
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10 mg 20 mg 40 mg 60 mg 80 mg 90 mg
The appearance of these tablets Is a registered trademark of Ayerst Laboratories.
Once-daily
80 120
mg mg
(PR0PR4N0L0L HQ) “ps™
The appearance of these capsules is a registered trademark of Ayerst
HAL U
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Laboratories
BRIEF SUMMARY (FOR FULL PRESCRIBING INFORMATION, SEE PACKAGE CIRCULARS )
INDERAL^ (propranolol hydrochloride) Tablets and Injectable
INDERAL'S LA (propranolol hydrochloride) Long Acting Capsules
INDICATIONS AND USAGE— INDERAL Tablets
Hypertension: INDERAL (propranolol hydrochloride) is indicated in the management of
hypertension. It may be used alone or used in combination with other antihypertensive
agents, particularly a thiazide diuretic. INDERAL is not indicated in the management of
hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL is indicated for the
long-term management of patients with angina pectoris
Cardiac Arrhythmias:
1 ) Supraventricular arrhythmias
a) Paroxysmal atrial tachycardias, particularly those arrhythmias induced by cate-
cholamines or digitalis or associated with the Wolff-Parkinson-White syndrome. (See W-P-W
under WARNINGS.) b) Persistent sinus tachycardia which is noncompensatory and impairs
the well-being of the patient c) Tachycardias and arrhythmias due to thyrotoxicosis when
causing distress or increased hazard and when immediate effect is necessary as adiunctive,
short term (2-4 weeks) therapy. May be used with, but not in place of, specific therapy. (See
Thyrotoxicosis under WARNINGS.) d) Persistent atrial extrasystoles which impair the well-
being of the patient and do not respond to conventional measures, e) Atrial flutter and
fibrillation when ventricular rate cannot be controlled by digitalis alone, or when digitalis is
contraindicated.
2. ) Ventricular tachycardias
Ventricular arrhythmias do not respond to propranolol as predictably as do the supra-
ventricular arrhythmias. a)Ventricular tachycardias. With the exception of those induced by
catecholamines or digitalis, INDERAL is not the drug of first choice. In critical situations when
cardioversion technics or other drugs are not indicated or are not effective, INDERAL may be
considered If, after consideration of the risks involved, INDERAL is used, it should be given
intravenously in low dosage and very slowly. (See DOSAGE AND ADMINISTRATION.) Care in
the administration of INDERAL with constant electrocardiographic monitoring is essential as
the failing heart requires some sympathetic drive for maintenance of myocardial tone b)
Persistent premature ventricular extrasystoles which do not respond to conventional mea-
sures and impair the well-being of the patient.
3. ) Tachyarrhythmias of digitalis intoxication
If digitalis-induced tachyarrhythmias persist following discontinuance of digitalis and cor-
rection of electrolyte abnormalities, they are usually reversible with oral INDERAL. Severe
bradycardia may occur. (See OVERDOSAGE.) Intravenous propranolol hydrochloride is
reserved for life-threatening arrhythmias. Temporary maintenance with oral therapy may be
indicated (See DOSAGE AND ADMINISTRATION in the package circulars )
4. ) Resistant tachyarrhythmias due to excessive catecholamine action during anesthesia.
Tachyarrhythmias due to excessive catecholamine action during anesthesia may some-
times arise because of release of endogenous catecholamines or administration of cate-
cholamines When usual measures fail in such arrhythmias, INDERAL may be given
intravenously to abolish them All general inhalation anesthetics produce some degree of
myocardial depression. Therefore, when INDERAL (propranolol hydrochloride) is used to
treat arrhythmias during anesthesia, it should be used with extreme caution and constant
ECG and central venous pressure monitoring (See WARNINGS.)
Myocardial Infarction: INDERAL is indicated to reduce cardiovascular mortality in
patients who have survived the acute phase of myocardial infarction and are clinically stable
Migraine: INDERAL is indicated for the prophylaxis of common migraine headache The
efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL is useful in the management of hyper-
trophic subaortic stenosis, especially for treatment of exertional or other stress-induced
angina, palpitations, and syncope INDERAL also improves exercise performance. The
effectiveness of propranolol hydrochloride in this disease appears to be due to a reduction of
the elevated outflow pressure gradient which is exacerbated by beta receptor stimulation
Clinical improvement may be temporary.
Pheochromocytoma: After primary treatment with an alpha-adrenergic blocking
agent has been instituted, INDERAL may be useful as adjunctive therapy if the control of
tachycardia becomes necessary before or during surgery
It is hazardous to use INDERAL unless alpha-adrenergic blocking drugs are already in
use, since this would predispose to serious blood pressure elevation Blocking only the
peripheral dilator (beta) action of epinephrine leaves its constrictor (alpha) action
unopposed
In the event of hemorrhage or shock, there is a disadvantage in having both beta and
alpha blockade since the combination prevents the increase in heart rate and peripheral
vasoconstriction needed to maintain blood pressure.
With inoperable or metastatic pheochromocytoma, INDERAL may be useful as an ad|unct
to the management of symptoms due to excessive beta receptor stimulation
INDICATIONS AND USAGE— INDERAL LA Long Acting Capsules
Hypertension: INDERAL LA (propranolol hydrochloride) is indicated in the manage-
ment of hypertension; it may be used alone or used in combination with other antihyperten-
sive agents, particularly a thiazide diuretic INDERAL LA is not indicated in the management
of hypertensive emergencies.
Angina Pectoris Due to Coronary Atherosclerosis: INDERAL LA is indicated for
the long-term management of patients with angina pectoris.
Migraine: INDERAL LA is indicated for the prophylaxis of common migraine headache.
The efficacy of propranolol in the treatment of a migraine attack that has started has not been
established and propranolol is not indicated for such use.
Hypertrophic Subaortic Stenosis: INDERAL LA is useful in the management of
hypertrophic subaortic stenosis, especially for treatment of exertional or other stress-in-
duced angina, palpitations, and syncope INDERAL LA also improves exercise perfor-
mance. The effectiveness of propranolol hydrochloride in this disease appears to be due to a
reduction of the elevated outflow pressure gradient which is exacerbated by beta-receptor
stimulation. Clinical improvement may be temporary.
CONTRAINDICATIONS. INDERAL and INDERAL LA are contraindicated in 1) car-
diogenic shock; 2) sinus bradycardia and greater than first degree block; 3) bronchial
asthma; 4) congestive heart failure (see WARNINGS) unless the failure is secondary to a
tachyarrhythmia treatable with INDERAL.
WARNINGS. CARDIAC FAILURE. Sympathetic stimulation may be a vital compori
supporting circulatory function in patients with congestive heart failure, and its inhibition
beta blockade may precipitate more severe failure. Although beta blockers should1!
avoided in overt congestive heart failure, if necessary, they can be used with close follow)
in patients with a history of failure who are well compensated and are receiving digitalis j|
diuretics. Beta-adrenergic blocking agents do not abolish the inotropic action of digitali j
heart muscle
IN PATIENTS WITHOUT A HISTORY OF HEART FAILURE, continued use of beta bloci j
can, in some cases, lead to cardiac failure Therefore, at the first sign or symptom of h )
failure, the patient should be digitalized and/or treated with diuretics, and the respc)
observed closely, or INDERAL should be discontinued (gradually, if possible).
IN PATIENTS WITH ANGINA PECTORIS, there have been reports of exacerbation
angina and, in some cases, myocardial infarction, following abrupt discontinuance i
INDERAL (propranolol hydrochloride) therapy. Therefore, when discontinuance/
INDERAL is planned the dosage should be gradually reduced over at least a few week:
and the patient should be cautioned against interruption or cessation of therapy withoi
the physician's advice If INDERAL therapy is interrupted and exacerbation of angiri
occurs, it usually is advisable to reinstitute INDERAL therapy and take other measunl
appropriate for the management of unstable angina pectoris. Since coronary arte:
disease may be unrecognized, it may be prudent to follow the above advice in patier
considered at risk of having occult atherosclerotic heart disease who are given prj
pranolol for other indications
Nonallergic Bronchospasm (e.g., chronic bronchitis, emphyserm
PATIENTS WITH BRONCHOSPASTIC DISEASES SHOULD IN GENERAL NOT RECI
BETA BLOCKERS. INDERAL should be administered with caution since it may block tl
chodilation produced by endogenous and exogenous catecholamine stimulation of
receptors
MAJOR SURGERY The necessity or desirability of withdrawal of beta-blocking the
prior to major surgery is controversial. It should be noted, however, that the impaired abil
the heart to respond to reflex adrenergic stimuli may augment the risks of general anesth
and surgical procedures
INDERAL, like other beta blockers, is a competitive inhibitor of beta-receptor agonists
its effects can be reversed by administration of such agents, e.g, dobutamine or
proterenol However, such patients may be subject to protracted severe hypoten:
Difficulty in starting and maintaining the heartbeat has also been reported with I
blockers
DIABETES AND HYPOGLYCEMIA Beta-adrenergic blockade may prevent the
pearance of certain premonitory signs and symptoms (pulse rate and pressure change
acute hypoglycemia in labile insulin-dependent diabetes In these patients, it may be i
difficult to adjust the dosage of insulin
THYROTOXICOSIS: Beta blockade may mask certain clinical signs of hyperthyroic
Therefore, abrupt withdrawal of propranolol may be followed by an exacerbation of sj
toms of hyperthyroidism, including thyroid storm Propranolol does not distort thyroid f
tion tests
IN PATIENTS WITH WOLFF-PARKINSON-WHITE SYNDROME, several cases have t
reported in which, after propranolol, the tachycardia was replaced by a severe bradyc:
requiring a demand pacemaker In one case this resulted after an initial dose of E
propranolol
PRECAUTIONS. General Propranolol should be used with caution in patients
impaired hepatic or renal function INDERAL is not indicated forthe treatment of hypertef
emergencies.
Beta adrenoreceptor blockade can cause reduction of intraocular pressure. Pat
should be told that INDERAL may interfere with the glaucoma screening test. Withdr
may lead to a return of increased intraocular pressure
Clinical Laboratory Tests: Elevated blood urea levels in patients with severe heart dise
elevated serum transaminase, alkaline phosphatase, lactate dehydrogenase.
DRUG INTERACTIONS Patients receiving catecholamine-depleting drugs such as r
pine should be closely observed if INDERAL is administered The added catecholar
blocking action may produce an excessive reduction of resting sympathetic nervous ac
which may result in hypotension, marked bradycardia, vertigo, syncopal attack
orthostatic hypotension
Carcinogenesis, Mutagenesis, Impairment of Fertility Long-term studies in animals
been conducted to evaluate toxic effects and carcinogenic potential In 18-month studi
both rats and mice, employing doses up to 150 mg/kg/day, there was no evident
significant drug-induced toxicity. There were no drug-related tumorigemc effects at a
the dosage levels. Reproductive studies in animals did not show any impairment of fe
that was attributable to the drug.
Pregnancy: Pregnancy Category C. INDERAL has been shown to be embryotox
animal studies at doses about 10 times greater than the maximum recommended hi1
dose
There are no adequate and well-controlled studies in pregnant women INDERAL sf
be used during pregnancy only if the potential benefit justifies the potential risk to the f
Nursing Mothers INDERAL is excreted in human milk Caution should be exercised v
INDERAL is administered to a nursing woman
Pediatric Use Safety and effectiveness in children have not been established
ADVERSE REACTIONS. Most adverse effects have been mild and transient and
rarely required the withdrawal of therapy
Cardiovascular: bradycardia, congestive heart failure; intensification of AV block; t
tension; paresthesia of hands; thrombocytopenic purpura; arterial insufficiency, usua
the Raynaud type.
Central Nervous System Lightheadedness; mental depression manifested by msor,
lassitude, weakness, fatigue; reversible mental depression progressing to catatonia; v
disturbances; hallucinations; an acute reversible syndrome characterized by disorient
for time and place, short-term memory loss, emotional lability, slightly clouded senso
and decreased performance on neuropsychometrics.
Gastrointestinal nausea, vomiting, epigastric distress, abdominal cramping, diari
constipation, mesenteric arterial thrombosis, Ischemic colitis.
Allergic: pharyngitis and agranulocytosis, erythematous rash, fever combined with ac
and sore throat, laryngospasm and respiratory distress
Respiratory: bronchospasm
Hematologic agranulocytosis, nonthrombocytopenic purpura, thrombocytop
purpura L
Auto-Immune: In extremely rare instances, systemic lupus erythematosus has P/i
reported.
Miscellaneous: alopecia, LE-like reactions, psoriasiform rashes, dry eyes, male iii
tence, and Peyronie’s disease have been reported rarely Oculomucocutaneous reac
involving the skin, serous membranes and conjunctivae reported for a beta blocker (|,
tolol) have not been associated with propranolol.
REFERENCES.
1. Epstein FH, Rosa RM Adrenergic control of serum potassium N Engl J [j
1983;309:1450-1451 2. Vincent HH, Boomsma F, Man in't Veld AJ, et al: Effects of se!e|“
and nonselective 0-agonists on plasma potassium and norepinephrine. J Cardiovasc
macol 1984;6 107-114 3. Struthers AD, Whitesmith R, Reid JL Prior thiazide diuretic
ment increases adrenaline-induced hypokalaemia Lancet 1983,1 1358-1361 4. Brown
Brown DC, Murphy MB Hypokalemia from betap-receptor stimulation by circulating"
nephrine N Engl J Med 1983;309:1414-1419 5. Struthers AD, Reid JL, Whitesmith R.
Effect of intravenous adrenaline on electrocardiogram, blood pressure, and serun^
tassium Br Heart J 1983;49:90-93. 6. Holland OB, Nixon JV, Kuhnert L: Diuretic-indyl
ventricular ectopic activity. Am J Med 1981;70:762-768
9410/ 1
AYERST LABORATORIES
New York, N Y. 10017
Copyright © 1984 AYERST LABORATORIES
Division of AMERICAN HOME PRODUCTS CORPORATION
CLIP & SAVE-|
The Medical Society of New Jersey
and the Healthcare Information Network
Television Program Guide
September-May
(osed circuit television programs related to issues and concerns of physician members of MSNJ.
• PRESIDENT’S FORUM: hosted by Frank Y. Watson, M.D., President, MSNJ
• THE IMPAIRED PHYSICIAN: hosted by David I. Canavan, M.D., Director,
Impaired Physicians Program, MSNJ
• STATE OF THE ART: hosted by Howard D. Slobodien, M.D., Past President, MSNJ
lograms will be featured the first, second, and third Tuesday of each month at 1:00 p.m. There will be
ji 800 number for viewer participation.
lesented solely through those New Jersey hospitals which are subscribers to the HIN closed circuit
revision network. A listing of participating hospitals is on the bottom of this page.
hr additional information or comments, contact the Medical Society of New Jersey, Department of Special
lojects, A. Ronald Rouse, Director.
President’s Forum
: nk Y. Watson, M.D., President of
I Medical Society of New Jersey,
\ host this program with selected
imbers from the Board of Trustees
ii appropriate Council and Commit-
:< Chairpersons who will present in-
tmation discussed at the previous
Bard meetings.
a time for this program is financed
Dthe Medical Society of New Jersey.
Tuesday, October 2, 1984
Tuesday, November 6, 1984
Tuesday, December 4, 1984
Tuesday, January 1, 1985
Tuesday, February 5, 1985
Tuesday, March 5, 1985
Tuesday, April 2, 1985
Tuesday, May 7, 1985
I
The Impaired Physician
Air time for this program is financed
by the Health Care Insurance Ex-
change (HCIE) and the Princeton In-
surance Company (PIC).
Tuesday, September 11, 1984
“ Acute Case of the
Impaired Physician”
Tuesday, October 9, 1984
“Rehabilitation Programs”
Tuesday, November 13, 1984
“Aftercare”
Tuesday, December 11, 1984
“The Family and The Disease"
Tuesday, January 8, 1985
"Support Groups”
Tuesday, February 12, 1985
“Problems of Re-Entry”
Tuesday, March 12, 1985
“Followup/Monitoring”
Tuesday, April 9, 1985
“Recidivism/Special Problems"
State of the Art
Air time for this program is financed
by the Medical Society of New Jersey.
Tuesday, October 16, 1984
Professional Liability
James E. George, M.D., J.D.
and
Mr. Adam Wilczek
Tuesday, November 20, 1984
Continuing Medical Education
Paul Hirsch, M.D.,
Edwin Messey, M.D.
and
Robert Rigolosi, M.D.
Tuesday, December 18, 1984
MSNJ Legislative Activities
Mr. Joseph Katz
and
Mr. Clark Martin
The following programs will be an-
nounced at a later date:
Tuesday, January 15, 1985
Tuesday, February 19, 1985
Tuesday, March 19, 1985
Tuesday, April 16, 1985
Tuesday, May 21, 1985
’rticipating Hospitals*: Beth Israel Hospital; Freehold Area Hospital; Memorial General Hospital; Mor-
i:own Memorial Hospital; Northern Ocean Hospital System, Inc.; Pascack Valley Hospital; Saint Elizabeth
ispital; Saint Mary’s Hospital; Saint Peter’s Medical Center; and Underwood-Memorial Hospital.
Ispitals Declaring a Preliminary Interest: Atlantic City Medical Center; ACMC-Mainland Division; Betty
3charach Rehab. Hospital; Bridgeton Hospital; Carrier Foundation; Clara Maass Medical Center; Com-
r nity Memorial Hospital; Deborah Heart & Lung Center; Englewood Hospital Association; Hackensack
t dical Center; Holy Name Hospital; Hospital Center at Orange; John F. Kennedy Medical Ctr.; KMH/UMC-
>atford Division; Kessler Institute for Rehab.; Monmouth Medical Center; Muhlenberg Hospital; Newark
3ih Israel Medical Ctr.; Newton Memorial Hospital; Riverside Hospital; Salem County Memorial Hospital;
^ Saint Clare’s Hospital; Saint Francis Medical Center; Warren Hospital; West Hudson Hospital; and West
sey Hospital-Northern Division.
sting of hospitals may have changed since this printing.
CLIP & SAVE-
' >L.
81— NUMBER 12— DECEMBER 1984
1083
Pharmacological Basis of Therapeutics:
Dopamine Receptors*
Richard E. Heikkila, ph.d., piscataway**
Drugs that interact with dopamine receptorst either to facilitate
or to inhibit their actions , are important clinically. Dopamine
receptor agonists commonly are used to treat Parkinson patients.
In contrast , dopamine receptor antagonists commonly are used
as antipsychotic agents. An understanding of how these drugs
interact with their specific receptors is of clinical significance.
D
opamine (3,4-dihydroxyphenyl-
ethylamine) is formed from
dietary tyrosine after the ac-
tions of the enzymes, tyrosine hydroxylase and dopa
decarboxylase (Table 1). The enzyme dopamine-beta-
hydroxylase, which is missing from dopamine neu-
rons, forms norepinephrine from dopamine within
norepinephrine neurons. As recently as 1957,
dopamine was thought to be only an inactive precursor
of norepinephrine and to have no real importance of
its own.
After its release from its presynaptic storage pool
into a synaptic cleft, a number of things can happen
to dopamine. Firstly, and probably most importantly,
dopamine can bind to its receptors on a postsynaptic
membrane. This binding of dopamine to its receptor
is an initial step in a cascade of events which ultimate-
ly results in a biological response, e.g. movement. Syn-
aptically released dopamine also can be inactivated
and it is thought that the major mechanism for the
inactivation of dopamine is its reuptake back into the
presynaptic neuron. Dopamine also is inactivated by
the actions of the degradative enzymes, catechol-o-
methyl-transferase and monoamine oxidase. This lat-
ter enzyme exists in at least two different forms, a
monoamine oxidase A and a monoamine oxidase B.
There are several distinct dopamine pathways
within the mammalian central nervous system. The
nigrostriatal dopaminergic system, which is important
in proper motor coordination, is degenerated i
Parkinson’s disease. A second dopamine system, th
tuberoinfundibular, controls the release of pituit;
hormones such as prolactin. A third dopamine syste:
the mesolimbic, is thought to be involved with t
regulation of emotional behavior. For example, it is fei
that schizophrenics have an overactive mesolimbi
dopamine system and that the antipsychotic effects
neuroleptic drugs are due to their blockade of over
active dopamine receptors in areas of the brain inj
neivated by the mesolimbic dopamine system.7
Besides the above-mentioned antipsychotic agents)
there are several clinically used drugs that modulat
dopaminergic activity. For example, 1-dopa, the direc
precursor of dopamine, and other directly actinj
dopaminergic agonists such as bromocriptine
lergotrile, and pergolide, successfully have been usee
in the treatment of Parkinson’s disease. In addition te
‘This article, sixth in a series, prepared under the leadershif
of Bruce McL. Breckenridge, M.D., Chairman, Department o
Pharmacology, UMDNJ-Rutgers Medical School, is a brief re
view of recent advances in pharmacology and relatec
preclinical sciences, which will help readers to understanc
the action of new and established therapeutic agents. Th<
reviews do not consider indications for specific drugs, incom
patibilities, or dosage forms, which can be found in the AM/
Drug Evaluations, 5th Edition, 1983.
“From the Department of Neurology, UMDNJ-Rutgers Medi
cal School. Correspondence may be addressed to Dr. Heikkila
UMDNJ-Rutgers Medical School, Piscataway, NJ 08854.
1084
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
TABLE 1
tyrosine
tyrosine
hydroxylase
1-dopa
dopa
decarboxylase
dopamine
leir use as antiparkinsonian agents, several dop-
nine agonists have been used to control the secretion
prolactin. Mazindol, a compound which blocks the
■uptake of synaptically released dopamine, is used as
i anorexic agent while yet another dopamine uptake
locker, nomifensine, is utilized in Europe as an anti-
spressant.
In addition to these beneficial drugs, several drugs
abuse have dopaminergic activity. For example,
mphetamine and cocaine facilitate the release of
opamine and block the reuptake of synaptically re-
used dopamine, respectively. Both of these latter ae-
ons, facilitation of dopamine release and blockade of
opamine reuptake, would raise the effective
opamine level in the synaptic cleft that then could
iteract with the dopamine receptor. It is reasonable
d suggest that other dopamine uptake inhibitors or
opamine-releasing agents, like cocaine and amphet-
mine, may have potential for abuse.
The ultimate target of all drugs that interact with
opamine systems is the dopamine receptor. Drugs
hat enhance dopaminergic activity lead to a greater
timulation of the dopamine receptor and, conversely,
ilrugs that decrease dopaminergic activity lead to a
liminished stimulation of the dopamine receptor,
'here exists considerable evidence that there are mul-
iple classes of dopamine receptors. For the most part,
his evidence has been derived from biochemical
ind/or pharmacological experimentation done in vitro.
There are several schemes that exist for the classi-
fication of dopamine receptors.1 5-6-9 11 In these various
schemes, the number of subclasses of the dopamine
eceptor ranges from two to five. With so many classi-
ication schemes being used, it is not surprising that
i great deal of confusion exists in this field. What was
rue yesterday in fact may not be true today! Perhaps
i great deal of this confusion exists because the experi-
nents that form the basis of the classification schemes
ire simple to carry out, but at the same time are dif-
ficult to interpret. And oftentimes, the appropriateness
if the classification scheme is dependent upon a
number of assumptions, all of which not always are
obviously valid.
Probably the first classification scheme for dop-
amine receptors that gained a widespread acceptance
was that of Kebabian and Caine (Table 2). 5 Published
in 1979, this scheme is based upon the effects of a
TABLE 2
Classification of Dopamine Receptor Subtypes According
to Kebabian and Caine
Linked to adenylate
cyclase
Specific agonist
Specific antagonist
D-l Receptor
Positively
SKF 38393
SCH 23390
D-2 Receptor
Negatively
LY 141865
Sulpiride
drug on adenylate cyclase activity and on prolactin
secretion. According to this classification, stimulation
of the D-l dopamine receptor leads to increased cyclic
AMP formation. Stimulation of the D-2 dopamine re-
ceptor leads to no increment, and in fact a decrement,
in cyclic AMP formation. In contrast to its effects on
cyclic AMP formation, stimulation of the D-l receptor
has no effect on prolactin secretion while stimulation
of the D-2 receptor leads to an inhibition of prolactin
secretion.5 According to Kebabian and Caine, the D-l
dopamine receptors are found in several mammalian
tissues including the superior cervical ganglion, the
retina the neostriatum, and the parathyroid gland.
The D-2 dopamine receptors are located in various
tissues, including the neostriatum and the anterior
and intermediate lobes of the pituitaiy.
Dopamine and several other drugs including
apomorphine and pergolide, stimulate both the D-l
and D-2 dopamine receptor.2 Dopamine, for example,
is known to bring about increases in levels of cyclic
AMP and to inhibit prolactin secretion. In contrast, the
commonly used antipsychotic agents, haloperidol and
chlorpromazine, by themselves cause an increase in
prolactin secretion, and additionally can prevent the
dopamine mediated rise in cyclic AMP formation.5
These two drugs, therefore, are antagonists of both the
D-l and D-2 dopamine receptors. While these drugs
stimulate (or inhibit) both D-l and D-2 receptors, there
are other agents that are relatively specific and interact
with one or the other of these receptor subtypes. For
example, SKF 38393 is a D-l receptor agonist and has
little or no effect on D-2 receptors.10 In contrast,
LY- 14 1865 is a D-2 receptor agonist that has little or
no effect on D-l dopamine receptors.12 Specific an-
tagonists also exist. SCH 23390 is a D-l receptor an-
tagonist4 while sulpiride is a D-2 antagonist.9 And if
all of this is not confusing enough, there are drugs
including bromocriptine and several other structurally
similar ergot alkaloids that are D-l receptor an-
tagonists and D-2 receptor agonists.8 It is clear from
this information that the rather simple classification
scheme of Kebabian and Caine for dopamine receptors
can become quite complex.5
Another classification scheme for dopamine recep-
tors is put forth by Seeman.9 This classification
scheme, which is based strictly on radioligand binding
experiments, has four subclasses of dopamine recep-
tors. These four subclasses are called D-l, D-2, D-3, and
D-4 and are defined on the basis of their relative af-
finities for dopamine agonists, i.e. dopamine, and
dopamine antagonists, i.e. spiperone. As defined by
Seeman, the D-l receptor has a ^M affinity for
dopamine agonists and a juM affinity for dopamine
antagonists; the D-2 receptor has pM affinity for
dopamine agonists and nM affinity for dopamine an-
tagonists; the D-3 receptor has nM affinity for
dopamine agonists and //M affinity for antagonists;
VOL. 81— NUMBER 12— DECEMBER 1984
1085
and the D-4 receptor has nM affinity for both
dopamine agonists and antagonists. Another classi-
fication scheme based on radioligand binding, perhaps
less popular than that of Seeman, is that of Sokoloff
et al.11 In this scheme, the D-l and D-3 dopamine
receptors are defined exactly as by Seeman. However,
the definitions for the D-2 and D-4 receptors are exact-
ly reversed in these two schemes. Stated differently, the
D-2 receptor as defined by Seeman is identical to the
D-4 receptor as defined by Sokoloff et al.9 11 Accordingly,
the D-4 receptor in the Seeman classification is the
D-2 receptor as defined by Sokoloff et al. It is not sur-
prising that there is confusion, at least in the minds
of some. What adds even more to the confusion is that
all of these binding experiments, while easy to carry
out, are quite difficult to interpret. They further often
rest on rather dubious assumptions, usually in what
agent is used to define specific receptor binding. Even
more surprising is that this rather suspect primary
data often is analyzed by means of rather sophisticated
computer techniques. It is clear that the method of
data analysis is far superior to the method of data
collection.
While there may be reservations in the minds of
some, others have proceeded and seemingly made
sense out of the confusion. It recently has been pointed
out, again from binding experiments analyzed by so-
phisticated computer techniques, that a model can be
constructed in which there are only two dopamine
receptors.6 In this scheme, the D-3 receptor is a high
affinity agonist state of the D-l receptor. Moreover, the
D-4 receptor is the high affinity agonist state of the
D-2 receptor. In this model, the D- 1 and the D-3 states
are interconvertible as are the D-2 and D-4 receptors.
While it is too early to determine whether this model
is consistent with all of the diverse experimental ob-
servations, this scheme clearly has the potential to
make some method out of what has heretofore been
madness. It furthermore has the potential to bring
together observations based on binding experiments
with observations based on adenylate cyclase experi-
ments.
In terms of a time framework, all of these above
observations on dopamine receptors have been rather
recent. It is far too early to decide the physiological
relevance of these various classes of dopamine recep-
tors.3 For example, it is not clear if the ideal ant
Parkinsonian agent should possess both D-l and D-
receptor agonist properties, or in contrast should ii!
teract with only one subclass of the dopamine recepto
Conversely, it is not clear if the ideal antipsychoti
agent will have relative specificity or in contrast wi
be an antagonist of both (all) subclasses of tf
dopamine receptor. It is conceivable that situation!
will arise in which it is desirable to have specif
agonists or antagonists. It also is clear that in additioj
to having practical implications many of these agent,
have been extremely valuable tools which have helpe
to further our knowledge of dopaminergic function
REFERENCES
1 . Cools AR The puzzling ‘cascade’ of multiple receptors fc
dopamine. An appraisal of the current situation. Trends t
Pharmacol Sci 2:178, 1981.
2. Fuller RW, Clemens JA Komfeld EC, Snoddy HI,
Smalstig EB, Bach NJ: Effects of (8/3)-8-[(methylthio
methyl] -6-propylergoline on dopaminergic function and brail
dopamine turnover in rats. Life Sci 24:375, 1979.
3. Gershanik O, Heikkila RE, Duvoisin RC: Behavioral co
relations of dopamine receptor activation. Neurology 33:148!
1983.
4. Iorio LC , Barnett A, Leitz FH, Houser VP, Korduba C i
SCH 23390, a potential benzazepine antipsychotic wit
unique interactions on dopaminergic systems. J Pharmact
Exp Ther 226:462, 1983.
5. Kebabian JW, Caine DB: Multiple receptors fc
dopamine. Nature 277:93, 1979.
6. Leff SE, Creese I: Dopamine receptors re-explainei
Trends in Pharmacol Sci 8:463, 1983.
7. Mackay AVP, Iversen LL, Rossor M, Spokes E, Bird I
Arregui A, Creese I, Snyder SH: Increased brain dopamir
and dopamine receptors in schizophrenia Arch Gen Psi
chiatry 39:991, 1982.
8. Markstein R Neurochemical effects of some ergot deriv;
tives: A basis for their antiparkinson actions. J Neural Tran
51:39, 1981.
9. Seeman P: Nomenclature of central and peripher;
dopaminergic sites and receptors. Biochem Pharmact
31:2563, 1982.
10. Setler PE, Sarau HM, Zirkle CL, Saunders HL: The cer
tral effects of a novel dopamine agonist. Eur J Pharmact
50:419, 1978.
1 1. Sokoloff P, Martres MP, Schwartz JC: Three classes c
dopamine receptor (D-2, D-3, D-4) identified by binding stuc
ies with 3H-apomorphine and 3H-domperidone. Arch Pharmc
col 315:89, 1980.
12. Tsuruta K, Frey EA Grewe CW. Cote TE, Eskay R1
Kebabian JW: Evidence that LY- 14 1865 specifically stimu
lates the D-2 dopamine receptor. Nature 292:463, 1981.
1086
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
(brc2EZZ> the BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, CA 90057
For Full Prescribing Information, Please See PDR.
REFER TO
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Android 5 10 25
Methyltestosterone U.S.R Tablets
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DOCTOR’S
NOTEBOOK
Trustees' Minutes; UMDNJ
Notes; MSNJ Auxiliary:
Current Legislation;
Retired Lives Reserve; New
Members; Physicians
Seeking Location in
New Jersey
Trustees’ Minutes
October 21, 1984
A regular meeting of the Board of
Trustees was held on Sunday, Octo-
ber 21, 1984, at the Executive Of-
fices in Lawrenceville. Detailed
minutes are on file with the sec-
retary of your county society. A sum-
mary of significant actions follows:
President’s Report . . .
DRG (Medicare/Medicaid Waiver)
. . . Noted that a three-year waiver
extension application has been filed
with the U.S. Dept, of Health and
Human Services by Mr. Scibetta,
NJHA, and is on file at MSNJ head-
quarters.
Report of Executive Director . . .
(1) MSNJ 1984 Paid Membership
. . . Noted that paid membership
was 7,497, as of September 28, 1984.
(2) MSNJ Financial Statements
. . . Noted that financial statements
for the periods ending August 1984
and September 1984 were reviewed
and approved.
(3) Reinsurance Association Defi-
cit . . . Noted that a task force is
being formed by Commissioner
Goldstein to study the medical
malpractice deficit of the Re-
insurance Association and other re-
lated issues.
(4) Medicare Fee Freeze . . . Noted
that the AMA has filed a lawsuit on
the Medicare amendments in the In-
diana Federal District Court.
Note: By reason of the filing of a
motion for preliminary injunction,
members of the Indiana State Medi-
cal Association and/or the members
of AMA who have not received their
fee profiles from Medicare carriers
were granted a 15-day filing ex-
tension.
(5) Litigation Report . . .
(a) Subordinated Loan Certifi-
cates-lntemal Revenue Service . . .
Noted that a report still is pending.
(b) State Board of Medical Exam-
iners v Cruz . . . Agreed to partici-
pate amicus if this case is appealed.
(6) AMA Council on Long-Range
Planning and Development . . .
Congratulated Dr. Palma Formica
on her appointment to the AMA
Council on Long-Range Planning
and Development.
Committee on Impaired Physicians
. . . Approved the following rec-
ommendation:
That the Board of Trustees authorize the
scheduling, advertising, and necessary
expenditures for the spring conference
on the medical family.
Audit Review Committee . . . Ap-
proved the following recommen-
dations:
That the audited financial statements be
accepted and a copy thereof forwarded to
each component medical society.
That Ernst and Whinney be continued as
the external auditors.
Old Business . . .
(1) 1984 Annual Meeting Resolu-
tions . . .
(a) Blue Shield Participating Phy-
sician Agreements (Resolution #5)
• . . Voted not to take legal action
concerning Blue Shield’s partici-
pating physician agreements.
(b) Expanded Legislative Service
(Resolution *14) . . . Approved the
following new procedures for in-
forming members about legislative
issues: Council on Legislation will
meet quarterly with county and
specialty society representatives;
regulatory proposals will be subjects
of special memorandums to county
and specialty societies and hospital
medical staffs; a section of Th
Journal will contain a legislative up
date every other month.
(c) Collective Bargaining Agent fc
Physicians’ Services (Resolutio
*25) . . . Voted not to implemer
this resolution calling for MSNJ t
act as collective bargaining agent fc
its members, and directed the Cour
cil on Medical Services to researc
and consider the development (
suggested relative value guideline
for the various specialties in Ne>
Jersey.
(2) Public Relations Program . .
Referred to the Council on Publi
Relations a request from the Unio
County Medical Society asking the
MSNJ implement a public relation
program addressed to senio
citizens in an effort to combat th
new Medicare regulations and up
coming DRG proposals.
New Business . . .
Physician Reimbursement in Re
habilitation Hospitals . . . Voted t
support the position being taken b
the NJ Society of Physical Medicin
and Rehabilitation which state
that the practice of medicine in re
habilitation institutions in New Jei
sey should not be treated different!
from that practiced generally acros
the country as it applies to Medicare
Also, voted to refer to the Council o
Medical Services for discussion th
overall topic of Medicare reimburse
ment.
UMDNJ Notes
Stanley S. Bergen, Jr., M.D.
President
A UMDNJ-Rutgers Medical Schoo
research group has found that twe
drugs— pargyline and deprenil—
prevent symptoms of Parkinson’s)
disease from developing in mice. The
advance was reported in the Octobei
4, 1984, issue of Nature. The UMDN<_
research team, which hopes to tes
the drugs in human patients, is lec
by Roger C. Duvoisin, M.D., professo:!
and chairman of the department o
neurology at the medical school; he
is an internationally known re
search specialist on Parkinson’s dis
ease.
This group was the first to suci
ceed in reproducing symptoms o
parkinsonism in mice. That was
achieved by injecting the laboratory
animals with a chemical contami
nant called MPTP. Then the scien
1088
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ists found that pargyline and
leprenil prevent MPTP-injected
lice from developing parkinsonism
ymptoms.
If those drugs succeed in halting
he progression of Parkinson’s dis-
ase in human patients, we will be
lot closer to solving the riddle of
his disorder.
Robert L. Johnson, M.D., director
f adolescent medicine at UMDNJ’s
[ewark campus, recently delivered a
tern message to the Congressional
Slack Caucus in Washington, D.C.
he associate professor of clinical
ediatrics at UMDNJ-New Jersey
ledical School stated that a rising
ide of violence is today the major
hreat to youth, particularly black
outh, and current methods of deal-
ig with it are ineffective and impo-
mt.
The violence Dr. Johnson spoke of
anges from automobile accidents to
uicide and homicide and often
rises from alcohol and drug abuse.
Wiile the teens are perceived as the
ealthiest age group, it is the only
ortion of the population in which
he rates of violent injury and death
re increasing, he said.
Dr. Johnson, speaking at the
lealth Brain Trust Workshop of the
4th Annual Congressional Black
laucus Legislative Weekend, called
nr "a new formula that will allow us
3 understand and respond to the
iolence that threatens our youth,”
nd asserted that traditional ap-
roaches to health care are ineffec-
ive in dealing with juvenile delin-
uency and related problems.
The UMDNJ physician, who is
'lack, believes that a “holistic” ap-
roach is necessary to “reach into
he lives of adolescents to determine
/here help is needed.” Traditional
pproaches to care must be broad-
ned. According to Dr. Johnson, the
ilea is to find a void in the youth’s
fe and then strive to fill it, through
areful followup and services.
A research team headed by John
V.C. Bird, Ph.D., director of the Bu-
sau of Biological Research at
Rutgers University, and Fred Roisen,
I.D., acting chairman of the depart -
lent of anatomy at UMDNJ-Rutgers
ledical School, has reported a natu-
al inhibitor to the cellular enzymes
aat cause the destruction of muscle
ells in muscle diseases.
In 1977, Dr. Bird and his col-
'agues discovered the enzymes re-
ponsible for the wasting of muscles
in diseases such as the muscular
dystrophies. Since they began work-
ing collaboratively, Drs. Bird and
Roisen’s groups have been able to
purify the enzymes, raise antibodies
to the enzymes, and, with the tech-
niques of fluorescent and electron
microscopy, demonstrate the actual
location and movement of the de-
structive enzymes in muscle cells.
The major significance of the new
finding is that we now have some
ideas on how the cell regulates these
destructive enzymes, or proteinases,
with its own endogenous inhibitor
under normal conditions. With
purified inhibitor and antibodies to
the inhibitor now available, several
exciting research possibilities exist
which involve the design of better
synthetic inhibitors and gene clon-
ing. In the future, it may be possible
by genetic engineering to insure
that patients have enough of this
inhibitor.
The Melvyn H. Motolinsky Foun-
dation, which supports research on
blood diseases, particularly leu-
kemia, announced the first recipient
of a permanent fellowship at
UMDNJ-Rutgers Medical School,
which houses the Foundation’s Lab-
oratory for Hematology Research at
its New Brunswick campus. The
Melvyn H. Motolinsky Foundation
was established in 1972 in memory
of its namesake, an attorney who
died of leukemia in 1969 at the age
of 26. Kathleen Toomey, M.D., re-
ceived the $25,000 award. She is in
her third year of postgraduate train-
ing at the UMDNJ school.
MSNJ Auxiliary
Grace Gellman
President
We are at the midpoint of the Aux-
iliary year. County community ser-
vice programs are in progress.
The fundraising projects are tak-
ing shape. Those marvelous parties
will be realities in a few months. It
takes a year of hard work to produce
such an affair, the proceeds from
which benefit community-based
programs, health-related scholar-
ships, and grants or loans to stu-
dents.
Your Auxiliary’s President-elect,
Mrs. Charles Moloney, and I have
been privileged to represent New
Jersey at the State Medical Auxiliary
conventions in Virginia, West Vir-
ginia, Pennsylvania, and New York.
Our Legislation Chairman, Mrs.
Frank Campo, is arranging what has
become an annual trip to Washing-
ton, D.C., where we meet with our
respective legislators. This year the
trip will be April 17-18, 1985. Aux-
iliary members from neighboring
states have expressed interest in
joining us.
Keep thinking “Convention” in
Lancaster, Pennsylvania, May 3-5,
1985. Mrs. Joseph Basralian and
Mrs. John Holdcraft are working
hard to make it a winner. Golf, ten-
nis, and bridge tournaments will be
held — come join us at Americana
Host Farm.
The holiday season is upon us.
Best wishes for a happy one!
Current Legislation
The Board of Trustees of the Medi-
cal Society of New Jersey approved
the recommended positions on the
following bills of medical interest,
unless noted otherwise:
S-331 -Lynch— Medicaid. Requires
Medicaid to provide treatment for pa-
tients that are drug abusers. The treat-
ment must be prescribed by a physician
and provided in an approved facility. Ap-
proved (Doctor Lehr voted in the
negative and asked to be so recorded).
S- 1 1 77-Gagliano — Jury Duty. Revises
the jury selection system in New Jersey.
Every citizen of the United States over
the age of 18 and residing in New Jersey
will be placed on the pool list. Existing
exemptions for police, fire, health care
personnel, etc., are repealed. Disap-
proved, because inclusion of health care
professionals will cause unwarranted
disruption in the provision of health care
services to the ill and injured residents
of New Jersey.
S- 1287-Gagliano— Criminal Re-
sponsibility. Abolishes insanity as a de-
fense. Allows mental health to be con-
sidered a mitigating factor in sentencing.
Action Deferred, pending further infor-
mation from the Council on Mental
Health.
S-1295-Lynch— Athletic Trainers.
Licenses athletic trainers through the
State Board of Medical Examiners. They
can provide physical treatment modal-
ities ordered by a licensed physician.
They must be employed by a school, col-
lege, university, or professional team. No
action.
S-1342-Lesniak— Pesticides. Regu-
lates the manufacture, use, and disposal
of pesticides. Authorizes and directs the
Department of Environmental Protec-
tion to prevent the contamination of
water supplies. Approved.
S-1504-Graves— Lead Poisoning
(same as A- 1048). Requires the Depart-
ment of Health to screen high-risk chil-
dren between the ages of one to five years
for lead poisoning. A similar bill passed
the Legislature last year, but was con-
OL. 81— NUMBER 12— DECEMBER 1984
1089
ditionally vetoed by the Governor. His
concerns have been addressed in S- 1 504.
Approved.
S-1513-Codey— Medicaid. Prohibits
administrators of nursing homes from
requiring incoming patients or their
families to sign agreements to stay as
private patients when they are eligible as
Medicaid patients. Also prohibits the
divesting of assets within 24 months of
an application for Medicaid eligibility.
Disapproved, Medicaid payments to hos-
pitals are based on the same rates as
those paid by, or on behalf of, all other
patients. Medicaid payments to nursing
homes are below the rates fairly charged
to other patients. As a result of Medicaid
patients not paying a fair rate, all other
patients are charged more. Medicaid pa-
tients and families with assets should
make a contribution to a fair rate.
S-1515-Codey— Nursing Homes.
Prohibits nursing homes from refusing
to accept Medicaid recipients if their oc-
cupancy level is below the statewide aver-
age as calculated by the Commissioner of
Human Services. Exceptions can be
granted based upon bed capacity and
financial status of the institution. No Ac-
tion.
S- 1534-Cowan— Antitrust Immunity.
Expands immunity from antitrust suits
to licensing boards to include their ac-
tions regarding admittance to a pro-
fession, suspension, and revocation of
licenses. Disapproved, because members
of licensing boards should continue to be
legally responsible for their decisions
and actions. (Drs. Lehr, Allen, Salerno,
and Sachs voted for an upgraded pos-
ition of Active Opposition and requested
to be so recorded.)
S-1557-Russo— Wrongful Death of
Minors- Damages. Permits the awarding
of compensatory damages in cases of
wrongful death of minors. There would
be a limitation of $100,000. (Current law
limits these awards to pecuniary loss,
together with established special dam-
ages.) Disapproved, because only dam-
ages established by proof should be sub
ject to award. Supreme Court decisions
in New Jersey have established a reason-
able and workable format for awarding
damages in wrongful death actions. This
bill would create an unwarranted ex-
pansion and escalate the cost of casualty
insurance without any benefit to the
public.
S-1584-DiFrancesco— Abuse of
Elderly Disabled or Incapacitated Per-
sons. Requires every person who has
reasonable cause to believe an elderly or
disabled person is the victim of abuse or
exploitation to report that information to
the Commissioner of Human Services or
his designee. Approved.
S- 1 650-Ewing— Biotechnology ( same
as A- 1764). This bill establishes the ad-
vanced technology center in biotech
nology on the adjoining campuses and
under the joint governance of Rutgers,
The State University, and UMDNJ. The
purpose of establishing this center is to
promote the development of biotech-
nology research, and to stimulate ad-
ditional job opportunities and new bus!
ness in this state. This bill implemen
recommendation 1 of the report of tf
Governor's Commission of Science ar
Technology. Approved.
S-1654-Ewing— Science and Teel
nology (same as A- 1767). This b
creates a New Jersey Commission on Sc
ence and Technology in the Departmer
of Commerce and Economic Develo]
ment. This bill implements recommer
dation 38 of the report of the Governor
Commission on Science and Technolog
This new agency will have the respons
bility for formulating long-range plar
and programs for science and technolog
in New Jersey. Approved.
S-1714-Bassano — Podiatric X-ra
Technicians. Licenses podiatric x-ra!,
technicians and allows them to take > ;
rays of the "leg* and foot area." Thei
curriculum and examination will be es
tablished and conducted by the Radio 4
logic Technology Board of Examiner:1
(‘Note: Current law limits the podiatris
to the "lower leg" and foot.) Active Op
position, this legislation is inferior t
S-515 which, adequately, addresses th
issue.
S-1717-Lynch— Education Bom
Fund. Creates an $80 million bond fun<
to finance the construction of a networl
of advanced technology centers at private
and public institutions of higher educa
tion. Approved.
S- 1 720-Bassano — Marriage Certifi
cates. Requires all female marriag
license applicants under age 45 to under
go rubella testing in addition t(
serological testing. Conditional Ap
proval, pending amendment "that thi:
bill will expire in ten years."
S-1721-Bassano— Rh Testing. Re
quires every physician attending £]
woman at the time of delivery, miscar
riage, abortion, or during the prenata
period to secure an Rh test. If the test is
Rh negative the physician, within 24
hours of receipt of the results, shall ad
vise the woman of its significance anc
the availability of preventive treatment
Disapproved, as unnecessary legislation
and the practice of medicine by legis
lation. This procedure already is being
done in physicians' offices and should;
remain a matter within the professional'
judgment of the physician.
S-1756-McManimon— Acupuncture;
(same as A-2025). Provides that!
acupuncturists licensed in another state:
immediately shall be eligible for appoint-
ment to the Acupuncture Examining)
Board. No Action (Law c.76 (1984)).
S-1775-Orechio — Chiropractic. A1-'
lows chiropractors who are licensed to'1
practice by written examination in any
state and who have completed 4,300
classroom hours in a chiropractic school
to become licensed to practice by virtue
of a clinical examination. Active Opposi-
tion, current law (which is now within
the purview of the State Board of Medical 1
Examiners) is preferable to this legis-
lation.
S-1828-O’Connor— Licensing of
Dietitians and Dietetic Technicians
(Same as A-2070). Requires the licensing
of dietitians and dietetic technicians
through the State Board of Dietetics.
Daily Schedule
219th Annual Meeting
May 2-5, 1985
Americana Host Farm Resort
Lancaster, Pennsylvania
Thursday, May 2, 1985
9:00 am — Registration Opens
9:00 am — Message Center Opens
2:00 p.m— House of Delegates
4:00 p.m— Reference Committees (Three Reference Committee Meetings)
Friday, May 3, 1985
7:30 am. — Registration Opens
9:00 am — House of Delegates (election)
9:00 am — Message Center and Exhibits Open
12:00 noon— Golden Merit Award Ceremony Followed by Reception
2:30 p.m— Reference Committees (Three Reference Committee Meetings)
5:00 p.m. — JEMPAC Political Forum
5:45 p.m. — JEMPAC Wine and Cheese Reception
Saturday, May 4, 1985
8:00 am.— Registration Opens
8:30 am — House of Delegates
9:00 am — Message Center and Exhibits Open
1:30 p.m. — House of Delegates
6:30 p.m — Inaugural Reception followed by Inaugural Dinner
Sunday, May 5, 1985
8:00 am. — Registration Opens
9:00 am — Message Center and Exhibits Open
9:00 am. — Program of Major Interest to Physicians
12 noon— Luncheons and Board of Trustees’ Meeting
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1090
Hetetics is defined as the application of
ne principles of the science of food and
utrition for the development and man-
gement of nutrition services to attain
nd maintain health. It includes evalu-
tion and consultation. Approved.
S- 183 9 -Dal ton — Guardianship,
mends existing law to allow a psychol-
gist to supply evidence of a need for
uardianship of a minor who is in the
jstody of the Division of Mental Re-
irdation. Active Opposition, decisions
f this nature should be made under the
jpervision of a psychiatrist, not a
inical psychologist.
S- 1840-Cardinale— Certificate of
eed. Exempts the private practice of
ledicine from the certificate of need law.
ctive Support.
S- 1846 -Garibaldi- Disability.
rovides that cancers caused by ex-
osure to heat, radiation, or a known
arcinogen which manifest themselves
1 active police and firemen are assumed
) be accidental and work-related dis-
bilities. Active Opposition, this legis-
ition is an intrusion on the private prac-
ce of medicine and improperly and in-
orrectly produces a diagnosis by legis-
ition.
SR-25-Cardinale— Certificate of
feed. Authorizes the Senate Institu-
ions. Health, and Welfare Committee to
onduct an investigation of certain
ertificate of need denials in northeast
tergen County. No Action.
SR-45-Pallone. A Senate resolution
lemorializing the Congress of the Unit-
d States to enact legislation to extend
ndefinitely New Jersey’s Medicare
waiver which allows the state to set hos-
ital rates for the Medicare and Medicaid
rograms. No Action.
A- 5 24- Weidel — Life -Sustaining
Procedures. Provides that terminally ill
>atients may direct their physicians,
hrough a written document to withhold
r withdraw mechanical or artificial
!neans to sustain or supplant vital func-
ion when those acts only artificially will
irolong death. The directive shall comply
IVith statutory form. The physician rely-
ng upon it shall determine it complies
vith the statute. No Action (refer to the
Committee on Biomedical Ethics for re-
tort back to the Council on Legislation
it its October meeting).
A-1048-Villame— Lead Poisoning
same as S-1504). Requires the Depart-
nent of Health to screen high-risk chil-
Iren between the ages of one and five
rears for lead poisoning. A similar bill
massed the Legislature last year, but was
onditionally vetoed by the Governor. Ap-
proved.
A- 1438 -Schwartz— Athletic Trainers.
Same as S-1295 with minor differences.
fo Action.
A- 1539-Doyle— Acupuncture. Creates
i separate Acupuncture Examining
Board with regulatory authority. No Ac-
ion.
A- 1559 -Garvin— Breast Cancer-In-
ormed Consent. Requires the Depart-
ment of Health and the State Board of
Medical Examiners to prepare a booklet
an all aspects of the treatment of breast
:ancer. Attending physicians are re-
quired to distribute the book to ap-
propriate patients and to discuss it with
them. Active Opposition, physicians
have the medicaJ-legal obligation to se-
cure informed consent from all their pa-
tients regardless of the condition in-
volved. The legislature should not be-
come involved in specific acts of medical
judgment and patient information.
These must be developed by science,
education, and standards of practice. If
codification is necessary that is a func-
tion of the appropriate regulatory agen-
cies.
A-1677-Biyant— Medical Education.
Provides for the Chancellor of Higher
Education to contract with Meharry
Medical College and School of Dentistry,
located in Nashville, Tennessee, to export
five to ten medical students and three to
five dental students into each Meharry
class. Admission will be solely on
academic merit. Students shall come
from a disadvantaged or minority back-
ground. Disapproved, the purpose of
this bill best can be resolved by utilizing
educational facilities within the state.
A- 1682-Muhler— Psychiatric Review-
Criminally Insame. Creates a seven per-
son board within the Department of
Human Services vested with the
authority to release or continue the com-
mitment of persons who were found in-
capable of standing trial or not guilty by
reasons of insanity. A Superior Court
judge currently makes these decisions.
Active Opposition, this authority should
remain within the jurisdiction of the Su-
perior Court judge. The Court is more
experienced in objectively evaluating the
evidence presented and the needs of the
individual and society in general.
A- 1 688-Shusted — Anatomical Gifts.
Requires hospitals to ascertain, when-
ever possible, whether a patient has
made an anatomical gift and to make
that information a part of the record. No
Action.
A- 1764-Gill— Biotechnology. This bill
establishes the advanced technology
center in biotechnology on the adjoining
campuses and under the joint gov-
ernance of Rutgers, The State University,
and UMDNJ. The purpose of establishing
this center is to promote the develop-
ment of biotechnology research, and to
stimulate additional job opportunities
and new business in this state. This bill
implements recommendation 1 of the re-
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jer-
sey. This special issue illuminates the beginnings of our
health care system and the growth of medical care: essays
highlight those talented individuals who devoted themselves
to this system, and commentaries present the development
of specialized care in associated fields of medicine. Plus a
special photography section highlighting three statewide
exhibits.
Copies of this issue are available by sending $5.00
(check or money order) to MSNJ, Two Princess Road, Law-
renceville, NJ 08648. All MSNJ members will receive one copy
of this issue.
Name
Address
Enclose a $5.00 check or money order for each copy.
VOL 81— NUMBER 12— DECEMBER 1984
1091
port of the Governor’s Commission on
Science and Technology. Approved.
A-1767-GU1— Science and Tech-
nology. This bill creates a New Jersey
Commission on Science and Technology
in the Department of Commerce and
Economic Development. This bill imple-
ments recommendation 38 of the report
of the Governor's Commission on Sci-
ence and Technology. This new agency
will have the responsibility for for-
mulating long-range plans and programs
for science and technology in New Jersey.
Approved.
A-1786-Gallo — Hemophilia. Requires
all hospital services contracts to include
services and products rendered at home
under the supervision of a state-ap-
proved hemophilia treatment center. Ap-
proved.
A-1787-Gallo — Hemophilia. Same as
A- 1786, applies to group health in-
surance contracts. Approved.
A- 1 788-Gallo— Hemophilia. Same as
A- 1787, applies to individual health in-
surance contracts. Approved.
A - 1829-Otlowski — Medicaid.
Prohibits families from encouraging
elderly relatives to divest assets in order
to become Medicaid eligible. Prohibits
hospitals, nursing homes, and inter-
mediate care facilities from receiving
contributions from Medicaid eligible in-
dividuals or their families at any time.
Prohibits a skilled nursing facility (SNF)
or intermediate care facility (ICF) from
denying admission on the basis of Medi-
caid coverage. (The Commissioner of
Human Services may make particular ex-
ceptions based on capacity or financial
condition of the facility. Prohibits the
SNF and ICF from leveraging private pay
status via contract prior to acceptance as
a Medicaid patient. Action Deferred, re-
cent amendments to the bill were not
available for Council review. This bill,
therefore, is referred directly to the Board
of Trustees, in amended form, for their
consideration and action.
A-1840-Kem — Wrongful Death. Re-
quires that when a wrongful death settle-
ment is "structured,” the Court will de-
termine prior to the settlement who will
receive and in what proportions. No Ac-
tion.
A-1854-Gallo— Alzheimer's Disease.
Increases the legislative members on the
Alzheimer’s Commission to give them a
majority. No Action.
A-1870-Garvin— Motor Vehicles.
Amends existing statutes to require
either belts or restraint systems for all
children under ten traveling in a motor
vehicle. Current law applies to children
under age five. Active Support.
A-1881-Perun — Insurance Coverage
of Organ Transplants. Requires medical
service corporations to provide coverage
for transplant procedures in their con-
tracts. No Action.
A-1882, 1883, 1884, 1885-Perun—
Organ Transplant. Requires health in-
surers and HMOs to cover organ trans-
plants in their contracts. No Action.
A- 1921 -Miller— Professional Liabili-
ty-Statute of Limitations. Establishes a
three-year statute of limitations in tort
actions against health care providers.
Children would have until age 1 1 to
bring an action for injuries prior to age
8. After age 8 they come under the three
year standard. Fraud concealment and
unintentional foreign bodies ‘‘toU" the
statute. Active Support.
A- 1922-Miller— Professional Liabili-
ty— Affidavit of Merit. Provides that
within 60 days of filing a medical
malpractice complaint, the plaintiff must
supply an affidavit, by a qualified expert,
that reasonable cause exists to believe
malpractice occurred. Active Support.
A- 1924-McEnroe— Nurse -Midwife.
Requires the Commissioner of Health to
establish a nurse-midwife prenatal dem-
onstration project at East Orange Gen-
eral Hospital in accordance with guide-
lines established by the Commissioner.
Action Deferred, pending further infor-
mation from the Essex County Medical
Society.
A-2070-Muhler— Licensing of Dieti-
tians and Dietetic Technicians (same as
S-1828). Requires the licensing of dieti-
tians and dietetic technicians through
the State Board of Dietetics. Dietetics is
defined as the application of principles of
the science of food and nutrition for the
development and management of nutri-
tion services to attain and maintain
health. It includes evaluation and consul-
tation. Approved.
A-2155-Otlowski-Use of Drugs by Op-
tometrists. Permits optometrists to use
topical drugs for treatment and
diagnostic purposes. Active Opposition,
optometrists are not medical doctors and
therefore should not be given the man-
date, via legislation, to administer drugs.
If the wrong medication is prescribed,
what could appear to be a simple prob-
lem could develop into destructive pro-
cess of the eye in a very short period of
time. The bill is short-sighted in attempt-
ing to provide lesser cost care to the gen-
eral public at the expense of the quality.
AR-25-Rocco— Nonviable Human
Fetuses. Requests the Commissioner of
Health to vigorously educate the public,
particularly young people, about the
dangers of cigarette smoking. Active
Support.
AR-62-Felice. An Assembly Resolu-
tion memorializing the Congress of the
United States to enact legislation to ex-
tend to January 1, 1986, New Jersey’s
Medicare waiver which allows the state
to set hospital rates for the Medicare and
Medicaid programs. No Action.
Retired Lives Reserve
On July 18, 1984, Pres. Reagan
signed into law the Tax Reform Bill
of 1984 which included the long-
awaited approval of the corporate
employee benefit Retired Lives Re-
serve. This plan was endorsed by the
Medical Society of New Jersey for its
membership in 1981.
Retired Lives Reserve is a tailored
fringe benefit program providing
permanent group term life in-
surance to reward select employees.
The concept offers a valuable asset
without the tax obligations by
providing: during employment, cor
ventional group term life insuranc
coverage; and at retirement, prepai
group term life insurance coverag
for life.
Assuredly, this is the ultimate ta;
favored method of purchasing lil
insurance. Both the group term an
reserve deposits paid by the corpoj
ation are fully deductible and are nc.
included in the physician’s gross ir
come. Benefits under a Retired Live
Reserve plan are not subject to iiT
come tax, gift tax, or federal estat
tax if properly arranged.
Initially, Retired Lives Reserve wa
conceived over 1 8 years ago for larg
public corporations, but was mad
available a few years ago to closel
held professional corporations. Aftej/
26 private letter rulings by the IR!
approving the Retired Lives Reserv
concept, it finally has become th
“law of the land.”
Physician advantages are:
1. Physician contribution: Nont
2. Provides postretirement in
surance coverage that is income tax
free, gift tax-free, and federal estat
tax-free.
3. Allows physicians to designate
beneficiary and assign ownershi]
rights to suit individual needs.
4. Lifetime death benefits.
5. No cost after retirement.
6. Death benefits continue afte
retirement regardless of status o
the corporation.
Corporation advantages are:
1. Provides impressive coverage
to benefit key people.
2. Total deposit paid by the cor
poration is tax deductible.
3. Corporation deposit ceases
upon retirement.
4. Reserve investment fund grows
on an income tax-free basis.
5. Plan cannot be cancelled by the
insurance company.
6. Stop and go provisions.
7. Simple and inexpensive to ad
minister.
The program endorsed by the:
Medical Society of New Jersey has
earned an average of 14.79 percent;
tax-free over the past five years. For
more information about the Medical
Society of New Jersey plan call or
write Joseph C. Lucci, Director olj
Medical and Insurance Affairs, 2
Princess Road, Lawrenceville, NJ
08648, (609) 896-1766.
William P. Squire, Jr.
President of Employee Benefits
of America, Inc., Washington, D.C.
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1092
Yew Members
The Journal of the Medical So-
iety of New Jersey would like to wel-
•ome the following new members:
Atlantic County
/larianito O. Asperilla, M.D., Atlantic City
Eduardo A Dijameo, M.D., Atlantic City
larry D. Glasser, M.D., Atlantic City
tobert M. Goldberg, M.D., Somers Point
ituart A Sackstein, M.D., Atlantic City
tergen County
lames J. Cappola, M.D., Englewood
/licael A. DeGennaro, M.D., Dumont
)ary J. Savatsky, M.D., Hackensack
lurlington County
tnthony D. Dippolito, M.D., Mount Holly
/lichael S. Entmacher, M.D., Moorestown
/lartin B. Laufe, M.D., Mount Laurel
lohn Francis McGrail, M.D., Mount Holly
tichard S. Murray. M.D., Mount Holly
Uan S. Penziner, M.D., Willingboro
)avid A. Popper, M.D., Mount Holly
‘hyllis J. Shetty, M.D., Mount Laurel
Martin S. Topiel, M.D., Mount Holly
Camden County
'homas J. O’Dowd. M.D., Cherry Hill
Dssex County
teynald Altema, M.D., Newark
Charles S. Goldberg, M.D., Montclair
.eonard JafTe, M.D., Bayonne
Philip E. Kline, M.D., Newark
Stanley J. Robboy, M.D., Newark
Gloucester County
Michael J. Denner, M.D., Woodbury
Hudson County
William P. Boyan, M.D.
George L. Colon, M.D., Jersey City
Dominick Condo, M.D., Jersey City
Keith A. Gresham, M.D., Jersey City
Patrick J. McGovern, Jr., M.D., Jersey City
Sooksan Traisakwatana, M.D.,
Jersey City
Hunterdon County
Joel R.L. Ehrenkranz, M.D. Morristown
Mercer County
Donna L. Brosbe, M.D., Trenton
Colleen A. Cooper, M.D., Trenton
Anil S. Deshpande, M.D., Trenton
Ernest E. Dorflinger, M.D., Trenton
Marcella M. Frank, M.D., Cherry Hill
Gary A. Karpf, M.D., Princeton
Charles S. Kososky, M.D., Trenton
Robert L. Moser, M.D., Trenton
William J. Mullally, II, M.D., Trenton
Aaron A. Spom, M.D., Trenton
Frederick M. Williams, M.D., Trenton
Monmouth County
Paul A. Caviale, M.D., Long Branch
Dale E. Edlin, M.D., Middletown
David S. Handlin, M.D., Long Branch
Bruce A Karmel, M.D., Englishtown
Irwin E. Landau, M.D., Hazlet
Kenneth W. Ordene, M.D., Freehold
Vicente C. Suoribio, Jr., M.D.,
Wanamassa
Robert L. Zanni, M.D., Long Branch
Morris County
Vincent B. Adamo, M.D., Parsippany
Donald M. Chervenak M.D., Florham
Park
Philip Felig, M.D., East Hanover
Thomas G. Fruzynski, M.D., Landing
Jesse S. Greenblum, M.D., Parsippany
Bohdan E. Halibey, M.D., Succasunna
Judith L. Magi, M.D., Florham Park
Lawrence C. Swayne, M.D., Morristown
Passaic County
Kishore K. Ahuja, M.D., Paterson
Henry H. Balzani, M.D., Clifton
Francis A D’Urso, M.D., Hawthorne
Arnold Olefson, M.D., Wayne
Tae Y. Park, M.D., Clifton
Rafael D. Pereira, M.D., Passaic
Steven H. Ressler, M.D., Saddle Brook
Frederic E. Wien, M.D., Paterson
Parvin A Zisman, M.D., Hewitt
Somerset County
Lee A Balaklaw, M.D., Somerset
Union County
Robert J. Bereik M.D., Rahway
Sanford Fineman, M.D., Union
Luis E. Garcia, M.D., Elizabeth
Steven J. Kalamaras, M.D., Elizabeth
Douglas J. Pravda, M.D., Kenilworth
John F. Vigorita, M.D., Summit
The Journal of the Medical Society of New Jersey
announces the reprinting of the
WILLIAM CARLOS WILLIAMS
COMMEMORATIVE ISSUE
September, 1983
Honoring the 100th anniversary of the birth of New Jersey’s prize-winning poet and physician.
Included in this handsomely illustrated, full-color issue will be original articles by persons
close to William Carlos Williams, artwork from his social and intellectual circle, and samples
of his finest writings.
Copies of this special issue are available by sending $5.00 for each (check or money order)
to MSNJ, Two Princess Road, Lawrenceville, NJ 08648.
Please send a copy of the William Carlos Williams Commemorative Issue to:
Enclose a $5.00 check or money order for each copy.
/OL. 81— NUMBER 12— DECEMBER 1984
1093
Physicians Seeking
Location in New Jersey
The following physicians have writ-
ten to the Executive Offices of MSNJ
seeking information on possible op-
portunities for practice in New Jersey.
The information listed below has been
supplied by the physician. If you are
interested in any further information
concerning these physicians, we sug-
gest you make inquiries directly to
them.
ANESTHESIOLOGY— Howard Ang, M.D.,
7-29 Hegeman Ave., #3-A Brooklyn, NY
11212. Far Eastern University 1976.
Group or partnership. Available Janu-
ary 1985.
DERMATOLOGY— Catherine A. Nordby,
M.D., 871 Beaconsfield, Grosse Pointe
Park, MI 48230. St. Louis 1980. Board
eligible. Specialty or multispecialty
group. Available July 1985.
EMERGENCY MEDICINE— Gerard B.
Martin, M.D., 871 Beaconsfield, Grosse
Pointe Park, MI 48230. St. Louis 1980.
Board eligible. Teaching hospital with
emergency medicine residency or
trauma center with research potential.
Available July 1985.
FAMILY MEDICINE— Maiy F. Cam
pagnolo, M.D., 10 Overlook Rd., Apt. 5-
E, Summit, NJ 07901. George Wash-
ington University 1982. Board eligible.
Group or partnership. Available July
1985.
Cary A. Davidson, M.D., 100B Findeme
Ave., Bridgewater, NJ 08807. SUNY-Up-
state 1982. Board eligible. Rural or
suburban practice, family practice,
solo, group. Available July 1985.
GASTROENTEROLOGY— Ronald J.
Cirillo, M.D., 7 Sandpiper Dr.,
Voorhees, NJ 08043. Guadalajara
(Mexico) 1978. Also internal medicine.
Board eligible (IM). Any type practice.
Available July 1985.
Kenneth Russell Feuer, M.D., 3120
Parkway, Cheverly, MD 20785. Baylor
1980. Also internal medicine. Board
certified (IM). Available July 1985.
Henry J. Katz, M.D., 20 Waterside Plaza,
New York, NY 10010. Albany Medical
College 1980. Board certified (IM).
Group or partnership. Available.
Steven M. Samuels, M.D., 4908 David
Court, Cincinnati, OH 45215. Louvain
(Belgium) 1980. Also internal medi-
cine. Board certified (IM). Group or
partnership. Available July 1985.
Eliot H. Zimbalist, M.D., 430 East 67
St., Apt. 12F, New York, NY 10021. Mt.
Sinai 1980. Also internal medicine.
Board certified (IM). Group, partner-
ship, multispecialty. Available July
1985.
INTERNAL MEDICINE— David M. Breid-
bart, M.D., 50 Hillpark Ave., Apt. 1-R,
Great Neck, NY 11021. SUNY-Down-
state 1979. Also pulmonary medicine.
Board certified (IM); board eligible
(PM). Pulmonary, pulmonary/intemal
medicine, multispecialty group. Avail-
able July 1985.
Ronald J. Cirillo, M.D., 7 Sandpiper Dr.,
Voorhees, NJ 08043. Guadalajcj
(Mexico) 1978. Subspecialty, gash-
enterology. Board eligible. Any ty;
practice. Available July 1985.
Kenneth Russell Feuer, M.D., 31:)
Parkway, Cheverly, MD 20785. Bay)-
1980. Also, gastroenterology. Boal
certified. Available July 1985.
Cory Krueger, M.D., 2301 Woodwal
St., Apt. C-12, Philadelphia, PA 191 1|
Rutgers 1982. Board eligible. Group •
partnership. Available July 1985.
Phillip A. Lecso, M.D., 5138 Regen
Dr., Toledo. OH 43615. Medical Collet
of Ohio 1982. Board eligible. Sing
multispecialty group, partnershi
Available July 1985.
Dominic Mazzocchi, M.D., 1231
89th St., Brooklyn, NY 11236. Puer
Rico 1981. Board eligible. Group I
partnership. Available January 1981
Gianfranco Umberto Meduri, M.D., 4G
East 67 St., Apt. 9C, New York, F
10021. Padua (Italy) 1977. Als
pulmonary. Board certified (IM
Group, academic, industrial. Availab
August 1985.
Richard Narvaez, M.D., 516 Berkley R<
Narberth, PA 19072. Temple 198
Group, partnership, HMO, solo. Aval
able July 1985.
Steven M. Samuels, M.D., 4908 Davi
Court Cincinnati, OH 45215. Louvai
(Belgium) 1980. Subspecialb
gastroenterology. Board certifier
Group or partnership. Available Ju]
1985.
Jerrold P. Schwartz, M.D., 69 Gold Si
Apt. 12-C, New York, NY 10038. Dijo
(France) 1982. Group, clinic, hospita
based, long-term care. Available Jul
1985.
Virod K. Shah, M.D., 345 Watkins Lam!
Battle Creek, MI 49017. M.P. Shai
(India) 1975. Board eligible. Any typ)
practice. Available.
Sarajane Stirling, M.D., 2329 Lombari
St., Philadelphia PA 19146. SUNY-Upl
state 1982. Board eligible. Group o
partnership. Available July 1985.
Robert L. Werner, D.O., 148 Reservoi
Rd., Parsippany, NJ 07054. UMDNJ
NJSOM 1981. Board eligible. Solo o
partnership. Available July 1985.
Lewis B. Zimet, M.D., 4313 Carambol;
Circle South, Coconut Creek, FI
33066. Far Eastern (Philippines) 1981
Board eligible. Solo, group, partner!
ship, industrial, or hospital-based
Available.
OBSTETRICS/GYNECOLOGY— Nissiir
Contente, M.D., 7300 Cedar Post Rd.
Apt. 10E, Liverpool, NY. Guadalajan
(Mexico) 1979. Board eligible. Group oi
partnership. Available July 1985.
Amnon Fein, M.D., 223 East Ave., Apt
6B, Syracuse, NY 13224. Guadalajara
(Mexico) 1980. Group or partnership
Available July 1985.
OPHTHALMOLOGY— George R Coar
M.D., 3245 Beechwood Blvd., Apt C-l 1,
Pittsburgh, PA. Jefferson 1981. Board
eligible. Group, partnership, solo. Avail-
able July 1985.
Medical Society of New Jersey
1985 Annual Meeting
The Medical Society of New Jersey will be conducting its 219th
Annual Meeting, May 2 through May 5, 1985, at the Americana Host
Farm Resort, in Lancaster, Pennsylvania
You can plan your arrival for Thursday, May 2nd with a Sunday,
May 5th departure.
There will be 500 rooms available at Host Farm Resort and an
additional 100 rooms available in the immediate area
The Hotel will maintain a shuttle bus service to and from the Host
Farm Building and the Host Corral Building.
This Annual Meeting will have total exclusivity of all function
rooms, dining rooms, golf and tennis facilities, entertainment, health
clubs, swimming pools, two miles of bicycle and jogging trails, hand-
ball, etc.
Sightseeing and factory outlet shopping here in the beautiful
Pennsylvania Dutch Country will be very appealing.
GET YOUR RESERVATION IN EARLY
1094
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Peter J. Famiglietti, M.D., Box 76, RD.
*5. Danville, PA 17821. University of
Connecticut 1981. Board eligible.
Group or partnership. Available July
1985.
Barry N. Shaklan, M.D., 6207 Black-
berry Lane, Dallas, TX 75248. Seton
Hall 1961. Board certified. Available.
ITHOLOGY— Steven P. Katz, M.D.,
9634 S. Karlov Ave., Oak Lawn, IL
60453. Nebraska 1972. Board certified
(PA and CLIN). Hospital or group. Avail-
able on one month’s notice.
DDIATRICS — Charles H. Geneslaw,
M.D., 8372 Loveridge Ct„ Richmond,
VA 23229. UMDNJ 1982. Partnership.
Available July 1985.
Suhaila Siddiqi Hussain, M.D., 104
Running Brook Rd. East, Ewing, NJ
08638. Baghdad (Iraq) 1979. Board
eligible. Group, partnership, solo. Avail-
able.
Nellie Novak, M.D., 1015 West Cherry
Hill Apts., Cherry HiU, NJ 08002.
Sverdlovsk (USSR) 1974. Board
eligible. Group, partnership, HMO.
Available July 1985.
JLMONARY MEDICINE— David M.
Breidbart, M.D., 50 Hillpark Ave., Apt.
1-R Great Neck, NY 11021. SUNY-
Downstate. Also, internal medicine.
Board eligible (PM); board certified
(IM). Pulmonary, pulmonary/intemal
medicine, multispecialty group. Avail-
able July 1985.
Gianfranco Umberto Meduri, M.D., 430
East 67 St., Apt 9C, New York, NY
10021. Padua (Italy) 1977. Also,
internal medicine. Board certified (IM).
Group, academic, industrial. Available
August 1985.
JRGERY— Victor P. Bruno, M.D., 702
Fordham Rd., Bala Cynwyd, PA 19004.
Georgetown 1978. Board eligible.
Group or partnership. Available May
1986.
Daniel M. Goldman, M.D., 3450 Wayne
Ave., Apt. 19-S, Bronx, NY 10467. Also,
vascular surgery. Board eligible. Part-
nership or single specialty group.
Available July 1985.
David A Guthrie, M.D., 3130 Heath-
stead PI., Charlotte, NC 28210. West
Virginia 1978. Also, vascular surgery.
Board eligible. Group or partnership.
Available July 1985.
JRGERY, VASCULAR— Daniel M.
Goldman, M.D., 3450 Wayne Ave., Apt.
19-S, Bronx, NY 10467. Also, general
surgery. Board eligible. Partnership or
single specialty group. Available July
1985.
David A Guthrie, M.D., 3130 Heath-
stead PI., Charlotte, NC 28210. West
Virginia 1978. Also, general surgery.
Board eligible. Group or partnership.
Available July 1985.
IOLOGY — Richard S.D. Tushman,
M.D., 519 Vantage PI., Richmond, VA
23236, Cornell 1980. Board eligible.
Available July 1985.
For patient’s
comfort/convenience
in choice of
LIPO-NICIN
Nicotinic Acid Therapy
A peripheral
vasodilator
for treatment of
leg cramps
cold feet
tinnitus
discomfort on
standing
3 strengths
Gradual Release
LIPO-NICIN®/300 mg.
Each time-release capsule con-
tains:
Nicotinic Acid 300 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
in a special base of prolonged
therapeutic effect.
DOSE: 1 to 2 tablets daily.
AVAILABLE: Bottles of 100, 500.
Immediate Release
LIPO-NICIN®/250 mg.
Each yellow tablet contains:
Nicotinic Acid 250 mg
Niacinamide 75 mg
Ascorbic Acid 150 mg
Thiamine HCL (B-1) 25 mg
Riboflavin (B-2) 2 mg
Pyridoxine HCL (B-6) 10 mg
DOSE: 1 to 3 tablets dally.
AVAILABLE: Bottles of 100, 500.
LIPO-NICIN®/100 mg. |§j§
Each blue tablet contains:
Nicotinic Acid 100 mg.
Niacinamide 75 mg.
Ascorbic Acid 150 mg.
Thiamine HCL (B-1) 25 mg.
Riboflavin (B-2) 2 mg.
Pyridoxine HCL (B-6) 10 mg.
DOSE: 1 to 5 tablets daily.
AVAILABLE: Bottles of 100, 500.
Indications: For use as a vasodi-
lator in the symptoms of cold
feet, leg cramps, dizziness,
memory loss or tinnitus when
associated with impaired peri-
pheral circulation. Also provides
concomitant administration of
the listed vitamins. The warm
tingling flush which may follow
each dose of LIPO-NICIN® 100
mg. or 250 mg. is one of the
therapeutic effects that often
produce psychological benefits
to the patient.
Side Effects: Transient flushing
and feeling of warmth seldom re-
quire discontinuation of the drug.
Transient headache, itching and
tingling, skin rash, allergies and
gastric disturbance may occur.
Contraindications: Patients with
known idiosyncrasy to nicotinic
acid or other components of the
drug. Use with caution in preg-
nant patients and patients with
glaucoma, severe diabetes, im-
paired liver function, peptic ul-
cers, and arterial bleeding.
Write for literature and samples
( BR<yCT?fc THE BROWN PHARMACEUTICAL CO., INC.
2500 West Sixth Street, Los Angeles, California 90057
)L. 81— NUMBER 12— DECEMBER 1984
1984-1985 MSNJ
Liaison Representatives
Academy of Medicine of New Jersey
(1) Board of Trustees/ Liaison Committee
(Liaison requested by Academy — June 19, 1966)
Alfred A. Alessi, M.D Hackensack
Arthur Bernstein, M.D South Orange
Sherman Garrison, M.D Bridgeton
(2) Postgraduate Medical Education Study Committee
(Representation requested by Academy— November 15, 1964)
Blood Banking Task Force for New Jersey
(University of Medicine and Dentistry of New Jersey — Octol r
1981)
Frank Campo, M.D Trent)
t
Blue Cross-Blue Shield Plans of New Jersey, Perman<
Committee on
(Appointment of Committee requested by MSP— April
1960)
Edwin W. Messey, M.D., Chairman, Committee on
Medical Education Willingboro
Stephen F. Wang, M.D., Member, Committee
on Medical Education Morristown
Agent Orange Commission, New Jersey
(Established by Governor— March 1980)
Frank Y. Watson, M.D., President Glen Rid
Vincent A Maressa Executive Director Lawrencev;
Equal representation from:
Medical-Surgical Plan of New Jersey
Hospital Service Plan of New Jersey
New Jersey Hospital Association
Laura E. Morrow, M.D Passaic
AMA-Education Research Foundation
(Liaison requested, by AMA— October 7, 1951)
David Greifinger, M.D., Chairman, Committee on
Medical Student Loan Fund Belleville
Archivist-Historian
(Appointment requested by the Medical History Society of
New Jersey — April 1982)
Morris H. Saffron, M.D New York, NY
Audit Review Committee (1983-1984)
(Appointed annually to review previous year’s audit)
Ralph J. Fioretti, M.D., President-Elect,
Chairman Rochelle Park
Joel S. Cherashore, M.D Nutley
Douglas M. Costabile, M.D Murray Hill
Edwin W. Messey, M.D Willingboro
Edward A Schauer, M.D.,First
Vice-President Farmingdale
Paul J. Hirsch, M.D., Treasurer, Consultant ... Bridgewater
Harry M. Carnes, M.D., Chairman, Committee on
Finance and Budget Audubon
Palma E. Formica M.D., Vice-Chairman,
Committee on Finance and Budget Old Bridge
Blindness, New Jersey Society To Prevent
(Requested by the Society for the Prevention of Blind-
ness— March 19, 1978)
Commissioner’s Physician Advisory Committee
(Representation requested by State Commissioner of Heal
to assist in the Diagnosis Related Group (DRG) co
cept — June 1977)
Frank Y. Watson, M.D., President* Glen Rid‘
’Douglas M. Costabile, M.D., Murray Hill, designated as Pre!'
dent’s representative for 1984-1985.
Diabetes Coordinating Council
(Representation requested by Department of Health
November 10, 1980)
Arthur Krosnick, M.D Trent(
DRG Position, Ad Hoc Committee on Presentation of MSP
(Established by Board of Trustees— December 19, 1982)
Alfred A. Alessi, M.D., Co-Chairman Hackensaij
Frank J. Primich, M.D., Co-Chairman West New Yoil
Stanley S. Bergen, Jr., M.D Newar
John P. Capelli, M.D Haddonfiej
James E. George, M.D., J.D Woodbu :i
Edwin W. Messey, M.D Willingboi
Myles C. Morrison, Jr., M.D Morristovvi
Gerald H. Rozan, M.D Wayr.
Howard D. Slobodien, M.D Metuche
Drug and Alcohol Problems, Statewide Committee To Assii
Local School Districts with
(Representation requested by Department of Education, Ri
gional Curriculum Services Unit-South — June 5, 1984)
Marc L. Engel, M.D., Chairman, Committee on
Conservation of Vision Holmdel
Blood Bank Association, New Jersey
(Liaison requested by New Jersey Blood Bank Associa-
tion— April 25, 1969)
Frank Campo, M.D Trenton
Ed Reading, M.Div Lawrencevil
Education, State Department of
(Liaison requested by the Assistant Commissioner of Educi;
tion — September 21, 1958)
Glenn P. Lambert, M.D., Chairman, Special
Committee on Child Health Flemingto:
1096
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
nergency Medical Personnel and Hospitals, Division on
omen Training Program for
epresentation requested by Department of Community Af-
irs. Division on Women— August 2, 1984)
pjdolf E. Schwaeble, M.D Mendham
tecudve Committee
rovided in the Bylaws, Chapter III (e))
•ank Y. Watson, M.D., President, Chairman ... Glen Ridge
ilph J. Fioretti, M.D., President-Elect Rochelle Park
iward A Sehauer, M.D., First
Vice-President Farmingdale
any M. Carnes, M.D., Second Vice-President .... Audubon
exander D. Kovacs, M.D., Immediate
Past-President Scotch Plains
rthur Bernstein, M.D., Secretary,
Consultant South Orange
ml J. Hirsch, M.D., Treasurer, Consultant ... Bridgewater
raduate Medical Education, Advisory Council on
^presentation requested by UMDNJ— 1979)
jwin W. Messey, M.D Willingboro
ealth Care Administration Board
:ep resen tatlve appointed by MSNJ— 1976 and July 1983)
dward A. Sehauer, M.D Farmingdale
Ronald Rouse, MSNJ Staff Member Lawrenceville
ealth Issues, Commissioner’s Special Committee on
Representation requested by Commissioner of Health — July
483)
ouglas M. Costabile, M.D Murray Hill
■ank Campo, M.D., Alternate Trenton
...
ealth Maintenance Organization Projects, Advisory
ommittee To Participate in the Review of
iecommended to Executive Director, State Health Coordi-
ating Council, Department of Health— 1974)
jenry J. Mineur, M.D Westfield
ealth Professions Education Advisory Council
’epresentative requested by Department of Higher Educa-
on— 1976)
filliam J. D’Elia, M.D Spring Lake
ealth Sciences Group, New Jersey
lembership requested by the Group — January 19, 1975)
dward G. Bourns, M.D Jamesburg
ml J. Hirsch, M.D., Treasurer Bridgewater
smard A. Rineberg, M.D New Brunswick
ealth Sciences Group Legislative Affairs Committee,
ew Jersey
-iaison requested by the Group— November 16, 1975)
Ung P. Ratner, M.D., Chairman, Council on
Legislation Willingboro
ighway Safety Policy Advisory Council, New Jersey
domination for appointment by Governor requested by Di-
ctor, Department of Law and Public Safety, Division of
otor Vehicles — March 19, 1984)
artin E. Johnson Lawrenceville*
Appointment pending
ospital Association, New Jersey
.iaison established at request of New Jersey Hospital As-
ixdation— December 17, 1967)
-ank Y. Watson, M.D Glen Ridge
EMPAC, Conference Committee with
iRstablished at request of JEMPAC — June 25, 1967
ving P. Ratner, M.D., Chairman, Council on
Legislation Willingboro
oseph W. Fleisher, M.D., Chairman, Council on
Medical Service Bayonne
any M. Carnes, M.D., Second Vice-President .... Audubon
OL. 81— NUMBER 12— DECEMBER 1984
Legislation
( 1 ) Federal Keymen (Mechanism established by MSNJ— April
4, 1954, to serve as official intermediaries between MSNJ and
the federal legislators): 14 Congressional District Keymen and
2 Senatorial Keymen.
(2) State Keymen (Mechanism established by MSNJ— July
13, 1952): Keyman in 40 legislative districts/21 component
societies.
Medical Assistance Advisory Council
(At the request of the New Jersey Department of Human
Services— 1 980)
Thomas S. Bellavia, M.D Hasbrouck Heights*
‘Appointment pending
Medical Assistants, State of New Jersey, Inc., American
Association of
(Liaison requested by Association— September 15, 1963)
Giovanni Lima, M.D Kearny
Medical Liaison Committees
(High-level conference groups for discussion and consider-
ation of items of mutual interest)
Frank Y. Watson, M.D., President Glen Ridge
Ralph J. Fioretti, M.D., President-Elect Rochelle Park
Edward A. Sehauer, M.D., First
Vice-President Farmingdale
Harry M. Carnes, M.D., Second Vice-President .... Audubon
Alexander D. Kovacs, M.D., Immediate Past
President Scotch Plains
Arthur Bernstein, M.D., Secretary South Orange
Paul J. Hirsch, M.D., Treasurer Bridgewater
Vincent A. Maressa, Executive Director Lawrenceville
(1) Medical-Dental
(Liaison requested by the Dental Society— June 10, 1951)
(2) Medical-Hospital
(Liaison established by MSNJ— October 25, 1953)
(3) Medical-Legal
(Liaison established by MSNJ— October 25, 1953)
(4) Medical-Nursing
(Liaison established by MSNJ— April 4, 1954)
(5) Medical-Osteopathic
(Liaison requested by Osteopathic
Association— September 17, 1961)
(6) Medical-Pharmaceutical
(Liaison established by MSNJ — July 26, 1953)
Mental Retardation, Governor’s Council on the
Prevention of
(Appointed by Governor— June 22, 1984)
Stanley S. Bergen, Jr., M.D Newark
Middlesex County Tercentennial— 300 Years of Medicine
Exhibit
(Liaison requested by Middlesex County— November 21,
1982)
Arthur Krosnick, M.D Trenton
Morris H. Saffron, M.D New York, NY
Peer Review Organization of New Jersey, Inc.,
Federation for
(Representation on Board of the Federation requested— June
1984)
Myles C. Morrison, Jr., M.D Morristown
Pharmaceutical Assistance to the Aged and Disabled
Advisory Council
(Appointed by Commissioner of the Department of Human
Services— physician representation requested by Division of
Medical Assistance— December 19. 1980)
Frank J. Malta, M.D Toms River
Pharmacopeial Convention, The United States
(MSNJ invited to appoint a delegate to serve— August 1980)
Frank J. Malta, M.D Toms River
1097
Physician Jury Service, Ad Hoc Committee on
(Appointed by President, pursuant to resolution adopted by
1983 House of Delegates)
L. Arne Skilbred, M.D., Chairman Glen Ridge
John J. Crosby, Jr., M.D Jersey City
Howard H. Lehr, M.D Fanwood
Irving P. Ratner, M.D Willingboro
Bernard A Rineberg, M.D New Brunswick
Poison Information and Education System, Advisory
Board to New Jersey
(Representation requested by Department of Health—
January 21, 1983)
Rudolf E. Schwaeble, M.D Mendham
Prescription Abuse Avoidance Committee
(Representation requested by State Board of Medical Exam-
iners—April 4, 1983)
David I. Canavan, M.D Lawrenceville
Daniel Greenfield, M.D Piscataway
Public Health Council, New Jersey
(Nomination for appointment by Governor to serve a seven-
year term requested by Department of Health — June 1, 1984)
Henry A. Katz, M.D Morristown*
‘Appointment pending
Radiation Protection, Advisory Committee on Nuclear
Medicine to New Jersey Commission on
(Consultant in nuclear medicine appointed by Com-
mission— November 20, 1966)
Henry J. Powsner, M.D Princeton
Radiation Protection, Consultant Serving New Jersey Com-
mission on
(Nomination for appointment to Commission requested—
March 17, 1963)
Frank Gingerelli, M.D Hackensack
Radiologic Technology Board of Examiners
(Agency of the Commission on Radiation Protection, Depart-
ment of Environmental Protection— appointed by Governor,
1983)
Armando F. Goracci, M.D Woodbury
Resolutions, Committee on Annual Meeting
(Established by Board of Trustees July 18, 1971, to review all
resolutions in advance of the Annual Meeting)
Armando F. Goracci, M.D., Chairman Woodbury
Howard D. Slobodien, M.D Metucli
Alexander D. Kovacs, M.D Scotch Pla i
Safety Council, New Jersey State
(Provided in Council Bylaws— 1962)
!
Frank Y. Watson, M.D., President Glen Ric<
George P. Bisgeier, M.D., President’s Representative, Chr
man, Special Committee on Occupational Health, Workt;
Compensation, and Rehabilitation New;k
State Board of Medical Examiners
(Trustees designated to attend monthly meetings on a rol
ing basis— per Board of Trustees December 15, 1974, a:
August 8, 1979)
Ralph J. Fioretti, M.D., President-Elect Rochelle P;<
Martin E. Johnson, MSNJ Staff Member Lawrencev ?
Statewide Health Coordinating Council (SHCC) and/or
Review Committee
(Liaison established January 15, 1978 — appointed by Pre-
dent of MSNJ)
Ralph J. Fioretti, M.D., President-Elect Rochelle Par'
A Ronald Rouse, MSNJ Staff Member Lawrencev ?
‘Appointed 1982. Doctor Fioretti will serve in this capacr
until he becomes President, at which time the new Seco I
Vice-President will serve as his replacement.
Student Association, MSNJ
(Formed— July 17, 1977)
Palma E. Formica, M.D Old Brid
L. Scott Stoney, Rutgers Medical School Piscataw;
Kevin Kerlin, New Jersey Medical School Newa
UMDNJ, Foundation of the
(MSNJ representative appointed yearly by the Board
Trustees to serve as a trustee, pursuant to the Bylaws of ti
Foundation— 1 979)
Arthur Bernstein, M.D South Oran;
Widows and Orphans of Medical Men of New Jersey, Tl>
Society for the Relief of
(Liaison requested by Society— May 17, 1959)
Joseph R Jehl, M.D.
Cliftc
Women Membership, Ad Hoc Committee on
(Established by Board of Trustees— December 19, 1982)
Carolyn W. Watson, M.D., Chairman Glen Rid|i
Roberta G. Rubin, M.D., Vice-Chairman ... Pompton Plair
Vivian Chen, M.D Brunswig
Janet Geraghty-Deutsch, M.D Jersey Ci
Birute S. Preikstas, M.D Oakhuni
1098
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
ME Calendar
The following is a list of
Continuing medical
education courses for the
i ext two months. Contact the
sponsoring organization for
further information.
|
i
his list is compiled through the coop-
ation of the Committee on Medical
ducation of the Medical Society of New
srsey, the Academy of Medicine of New
srsey, the New Jersey Chapter of the
merican Academy of Family Phy-
, clans, and the Office of Continuing
iedical Education of the UMDNJ. For
(formation on accreditation, please
antact the sponsoring organization(s),
i cheated by italics — last line of each
em.
NESTHESIOLOGY
an.
2 Dinner Meeting
6-9 P.M.— Ramada Inn, Clark
(NJ State Society of
Anesthesiologists andAMNJ)
ARDIOLOGY
eb.
9 Angina after Bypass Surgery
12 noon— St. Mary’s Hospital,
Orange
(AMNJ)
IEDICINE
an.
2 Internal Medicine Review Course
9 3-6 P.M.— Overlook Hospital,
6 Summit
3 (Overlook Hospital and AMNJ)
0
2 Endocrine Conferences
9 3:30-5 P.M. —Rotates between
6 Newark Beth Israel Medical Center,
13 University Hospital, United
10 Hospitals Medical Center, Newark,
and VA Medical Center,
East Orange
(Endocrinology Section and
AMNJ)
'OL. 81— NUMBER 12— DECEMBER 1984
2 Medical Grand Rounds
9 12 noon-1 P.M. — Rutgers Medical
16 School, Medical Education Bldg.,
23 New Brunswick
30 (UMDNJ and AMNJ)
2 Medicine Morbidity and Mortality
Conference
8-9 AM. — Rutgers Medical School,
Medical Education Bldg., New
Brunswick
(UMDNJ andAMNJ)
2 Immunoregulation : Basic
1 0 Concepts and Applications
17 4-6 P.M. —Institute for Medical
24 Research, Copewood St., Camden
31 (Institute Jor Medical Research
and AMNJ)
4 Renal Conferences in Nephrology
18 4-5 P.M. — UMDNJ-Rutgers Medical
School, Med. Education Bldg.,
Rm. 393
(Nephrology Society of NJ and
AMNJ)
8 Melanoma Precursors
8-10 P.M. —Schering Corp.,
Kenilworth
(NJ Dermatological Society and
AMNJ)
8 AIDS
8-9 AM.— Wayne General Hospital
(AMNJ)
9 AIDS
I -2 P.M.— VA Hospital, Lyons
(AMNJ)
15 Cocaine Abuse
12 noon— St. Mary’s Hospital,
Orange
(AMNJ)
16 Dermatological Conference
6-8 P.M. —Rutgers Community
Health Plan, U.S. Hwy. 1 & Rt. 18,
New Brunswick
(UMDNJ-Rutgers Medical School
and AMNJ)
1 7 New Concepts in Digoxin
Metabolism
I I AM.- 12 noon— St. Joseph’s
Hospital, Paterson
(St Joseph's Hospital and Medical
Center and AMNJ)
17 Geriatrics
3 P.M.— Ancora Psychiatric
Hospital, Hammonton
(AMNJ)
17 Whither Multiple Sclerosis?
5-7:30 P.M.— Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
24 Visiting Professorship Program
1:30-5 P.M. —Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center
and AMNJ)
30 Mitral Valve Prolapse
1-2:30 P.M.— VA Medical Center,
Lyons, Bldg. 93
(VA Medical Center and AMNJ)
Feb.
1 Renal Conferences in Nephrology
15 4-5 P.M — UMDNJ-Rutgers Medical
School, Med. Education Bldg.,
Rm. 393
(Nephrology Society oj NJ and
AMNJ)
6 Endocrine Conferences
13 3:30-5 P.M.— Rotates between
20 Newark Beth Israel Medical Center,
27 University Hospital, United
Hospitals Medical Center, Newark,
and VA Medical Center, Orange
(Endocrinology Section* AMNJ)
6 Internal Medicine Review Course
13 3-6 P.M. —Overlook Hospital,
20 Summit
27 (Overlook Hospital and AMNJ)
7 Immunoregulation: Basic
1 4 Concepts and Applications
21 4-6 P.M. —Institute for Medical
28 Research, Copewood St., Camden
(Institute Jor Medical Research
and AMNJ)
1 2 Virology in Dermatology
8-10 P.M. —Schering Corporation,
Kenilworth
(AMNJ)
20 Rutgers Dermatological
Conference
6-9P.M.— U.S. Hwy. 1 and Rt. 18,
New Brunswick
(UMDNJ)
2 1 The Thyroid— Its ups and Downs
5-7:30 P.M. —Somerset Medical
Center, Somerville
(Somerset Medical Center and
AMNJ)
28 New Treatment of Modalities and
Implications of Diabetes
1 1 AM.— St. Joseph’s Hospital &
Medical Center, Paterson
(AMNJ)
28 Visiting Professorship Program
1:30-5 P.M.— Saint Barnabas
Medical Center, Livingston
(Saint Barnabas Medical Center
and AMNJ)
NEUROLOGY/PSYCHIATRY
Jan.
3 Case Seminars and Supervision
17 To Improve Psychotherapeutic
Techniques
8-10 P.M.— 310 Harding Dr., South
Orange
(Advanced Psychiatric Study
Group andAMNJ)
7 Sexual Obsession in a 20-Year
Marriage
8:15-1 0:30 P.M — 1 1 1 Ridgewood
Ave., Glen Ridge
(Essex Psychiatric Seminar and
AMNJ)
1 7 Neurology: New Treatments of
Cerebrovascular Disease
2 P.M. —John E. Runnells Hospital,
Berkeley Heights
(AMNJ)
1 7 Psychodynamic Art Therapy
8-10 P.M. —Saint Barnabas Medical
Center, Livingston
(NJ Psychoanalytic Society and
AMNJ)
21 Lecture Series
8:30-10:30 P.M — 301 Broad Ave.,
Englewood
(NJ Psychoanalytic Society and
AMNJ)
Feb.
4 Mother-Daughter Fusion
1099
The Academy of Medicine of New Jersey
in cooperation with
Overlook Hospital
presents
“AN INTENSIVE REVIEW
OF INTERNAL MEDICINE”
JANUARY 16, 1985 to MAY 22, 1985
(19 Successive Wednesdays)
3:00 P.M.-6:00 P.M.
at
OVERLOOK HOSPITAL
SUMMIT, NEW JERSEY
The course is designed to provide a comprehensive review
contemporary concepts in Internal Medicine. It is designed f »
practicing internists and family practitioners. The review v
also be useful for residents. Syllabus material will be dil
tributed during the course which will, when compiled, provir
an extremely useful reference.
Course Chairman:
Michael Bernstein, M.D.
For further information on registration, faculty, and fee
please contact:
/r('yo/^ Tina D’Oria
^ Acaderr>y °f Medicine of New Jers<
£ ymU 5' Two Princess Road
v” Lawrenceville, NJ 08648
°. New Jersey Phone: (609) 896-1717
■ 11
!’
LIKOFF CARDIOVASCULAR INSTITUTE
of Hahnemann Medical College & Hospital
230 N. Broad Street, Philadelphia, Pennsylvania 19102 (215) 448-8063
CARDIOLOGY UPDATE. . .
IS DESIGNED FOR THE PHYSICIAN AND PROVIDES AN INTENSIVE SURVEY OF THE
CURRENT STATUS OF CLINICAL CARDIOLOGY. . .
WEDNESDAY, JANUARY 2, 1985
CARDIOMEGALY: DIFFERENTIAL DIAGNOSIS
MODERATOR: WILLIAM LIKOFF, M.D.
3:00 CASE PRESENTATION William S. Haaz, M.D.
3:30 DILATED CARDIOMYOPATHY: DIFFERENTIAL
DIAGNOSIS Stuart Snyder, M.D.
4:00 DILATED CARDIOMYOPATHY: VASODILATOR AND INOTROPIC THERAPY-
PASSION OR SKEPTICISM Mariell J. Likoff, M.D.
4:30 ACUTE RECURRENT PERICARDITIS: A THERAPEUTIC
CHALLENGE Daniel Mason, M.D.
5:00 CARDIAC TAMPONADE: PATHOPHYSIOLOGY AND
MANAGEMENT Harold Kay, M.D.
LECTURE HALL “A"— 2nd floor New College Building, Hahnemann University
15th and Vine Streets, Philadelphia, PA
• NO REGISTRATION FEE • NO ADVANCE REGISTRATION REQUIRED •
• CME CATEGORY I CREDITS CERTIFIED •
“WINE & CHEESE SERVED FOLLOWING CONFERENCE**
SIXTH ANNUAL
MINIRESIDENCY
IN OCCUPATIONAL MEDICINE
UNIVERSITY OF MEDICINE AND
DENTISTRY OF NEW JERSEY
DEPT. OF ENVIRONMENTAL AND COMMUNITY MEDICINE
RUTGERS MEDICAL SCHOOL
PISCATAWAY, NEW JERSEY 08854
DATE:
March 11-29, 1985/15 weekdays/8:30 a m. -4:30 p.m., 6
evening classes/6:30-8:30 p.m.
PURPOSE:
To provide a comprehensive review of key concepts in Occu-
pational Medicine given by eminent specialists from univer-
sity, government and industry. To aid in obtaining board
eligibility and certification.
ACCREDITATION:
The University of Medicine and Dentistry of New Jersey-Office
of Continuing Education certifies thal this continuing medical
education activity meets the criteria for 90 hours of credit in
Category I for the Physician’s Recognition Award of the
American Medical Association, provided the program is com-
pleted as designed.
SUBJECTS:
Industrial Hygiene, Occupational Disease, Toxicology, Prac-
tice of Occupational Medicine, Epidemiology and Biostatistics,
Ergonomics, Public Health Administration.
INQUIRIES: UMDNJ-Office of Continuing Education
Box 101, Piscataway, N.J. 08854
Patricia Reid (201) 463-4707
1100
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
8: 1 5- 1 0:30 P.M.— 9 Marquette Road,
Upper Montclair
(Essex Psychiatric Seminar and
AMNJ]
3 Sleep Apnea
1:30 P.M. — Essex County Hospital
Center, Cedar Grove
(AMNJ)
7 Diagnosis and Management of
Migraine
1 1 AM.— St. Joseph’s Hospital and
Medical Center, Paterson
(St Joseph's Medical Center and
AMNJ)
7 Case Seminars
21 8-10 P.M. — 310 Harding Drive,
South Orange
(Advanced Psychiatric Study
Group and AMNJ)
18 Lecture Series
8:30- 1 0:30 P.M — 30 1 Broad Ave„
Englewood
(NJ Psychoanalytic Society and
AMNJ)
21 Coordination Psychiatric
Treatment in the Hospital and
the Community
3 P.M.— Ancora Psychiatric
Hospital, Hammonton
(AMNJ)
The Journal of the
Medical Society of New Jersey
presents
300 YEARS OF
MEDICINE IN NEW JERSEY
September 1984
We are celebrating the history of medicine in New Jer-
sey. This special issue illuminates the beginnings of our
health care system and the growth of medical care: essays
highlight those talented individuals who devoted themselves
to this system, and commentaries present the development
of specialized care in associated fields of medicine. Plus a
special photography section highlighting three statewide
exhibits.
Copies of this issue are available by sending $5.00
(check or money order) to MSNJ, Two Princess Road, Law-
renceville, NJ 08648. All MSNJ members will receive one copy
of this issue.
Name _
Address
Enclose a $5.00 check or money order for each copy.
28 Third Annual Conference on
Emergency Psychiatry
Three days — Atlantic City
(O'Neill Lynch Associates, Wayne,
PA)
PEDIATRICS
Jan.
1 1 Extracorporeal Membrane
Oxygenation for Neonatal
Respiratory Failure
8-9:30 AM. — Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
Feb.
8 Controversies in Pediatric
Nutrition
8-9:30 AM. — Overlook Hospital,
Summit
(Overlook Hospital and AMNJ)
RADIOLOGY
Jan.
1 6 Combined Modality Therapy in
the Treatment of Unresectable
Carcinoma of the Pancreas
6:30- 1 0 P.M. — The Manor, West
Orange
(Radiotherapy Section and AMNJ)
1 7 Multimodality Approach to Renal
Disease
7:30-10 P.M. — Saint Barnabas
Medical Center, Livingston
(NJ Institute of Ultrasound in
Medicine and AMNJ)
Feb.
21 Radiology Meeting
7:30 P.M — Saint Barnabas Medical
Center, Livingston
(Radiological Society oj NJ and
Diagnostic Radiology Section.
AMNJ)
SURGERY
Jan.
1 5 Surgical Grand Rounds
29 7-9 AM — Hackensack Medical
Center
(Hackensack Medical Center and
AMNJ)
22 Malignant Hyperthermia
8-10 P.M. — Englewood Club,
Englewood
(Englewood Surg. Soc. and AMNJ)
Feb.
12 Surgical Grand Rounds
26 7-9 AM. — Hackensack Medical
Center
(Hackensack Medical Center and
AMNJ)
26 Venous Disease and Venous
Surgery
8-10 P.M.— Englewood Club,
Englewood
(Englewood Surgical Society and
AMNJ)
MISCELLANEOUS
Feb.
12 Malpractice
1 2 noon — West Jersey Hospital,
Camden
(AMNJ)
OL 81— NUMBER 12— DECEMBER 1984
1 101
ACUPUNCTURE IN CLINICAL PRACTICE
N.Y. State Boards of Medicine & Dentistry 25-hour accredited
seminar and workshop on the latest theories & techniques of
manual & electro-acupuncture and TENS, applicable toward the
200-hour requirement for certification, will be given for licensed
clinicians (with or without prior training) during the weekend of
Dec. 14-16, 1984 and again the weekend of Feb. 1-3, 1985 at
the Barbizon Plaza Hotel, New York City. Co-sponsored by the
International College of Acupuncture & Electro-Therapeutics, its
official journal, Acupuncture & Electro-Therap. Res., Int.J. (pub-
lished by Pergamon Press and indexed in 15 major indexing
periodicals; INDEX MEDICUS, etc.), the Heart Disease Research
Foundation and the Neuroscience Dept, of Long Island College
Hospital, Pharmacology Dept, of The Chicago Medical School.
Also eligible for AMA/CME credit. For information, contact Y.
Omura, M.D., ScD., 800 Riverside Drive (8-1), NYC 10032. Tel:
(212) 781-6262 or (212) WA8-0658, or Saul Heller, M.D., Tel:
(212) 838-7514.
Kirwan Financial Croup, Inc.
Financial Planners
for the
Medical Profession
Investments, Pensions, Insurance, Etc.
• Honest
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The Foundation provides a comple
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The Foundation is supported by an ir
house modern laboratory equipped to d
most tests required for diagnosis an
treatment. Literature on request.
1430 Second Avenue, Suite 103
New York, N.Y. 10021
Phone: (212) 744-5500
Neuroimaging Update 1985
February 1-6, 1985
Camino Real
Puerto Vallarta, Mexico
COURSE DESCRIPTION
This conference is designed for radiologists, neurologists, neurosurgeons and other physicians with interest in various
neuroimaging modalities. The program will provide a comprehensive and intensive review of the basic principles, practical
application and analysis of the current imaging techniques encompassing computed tomography, digital subtraction angio-
graphy, neurointerventional procedures, neuro-sonography and nuclear magnetic resonance. Emphasis will be on the new
exciting technology— N.M.R. which will be highlighted by a special session for the research and development presented
by the major NMR manufacturers. In addition, daily round table discussion with the faculty members will be conducted
during breakfast.
TUITION
The tuition for this course is $475.00 for physicians and $300.00 for residents in training with a letter of verification of status.
A refund of less than $50.00 will be made upon written request received prior to Dec. 15. 1984.
ACCREDITATION
20 hours of Category I, CME by American College of Radiology.
For Further Information, Contact:
S. Howard Lee, M.D. Course Director, (201) 668-3085; 3089 for course program. J. Brown Travel Agency, Travel Coordinator,
(315) 446-7600 for travel arrangements.
Price per person for “Land Arrangements” Package
Single
Double
COURSE
$785.00
$505.00
DIRECTOR
Seungho Howard Lee, M.D.
William G. Bradley, Jr., M.D., Ph.D.
Mokhtar Gado, M.D.
Burton P. Drayer, M.D.
Seungho Howard Lee, M.D.
Thomas P. Naidich, M.D.
Triple $425.00
Children $ 80.00
PROGRAM DIRECTORS
C.V.G. Krishna Rao, M.D.
Theodore Villafana, Ph.D.
FACULTY
C.V.G. Krishna RAO, M.D.
Theodore Villafana, Ph.D.
Meredith A. Weinstein, M.D.
Charles Citrin, M.D.
Gary DeFillip, M.D.
MUHLENBEtt, HOSPITAL II
Dept. Radiology and
Medical Education
Muhlenburg Hospita
Plainfield, N.J.
1102
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
BOOK REVIEWS
Basic and Clinical
Pharmacology; Current
Medical Diagnosis and
Treatment— 1984; Current
Gastroenterology;
Merritt's Textbook of
Neurology; The Source
Book of Plastic Surgery;
Symposium of Plastic and
Reconstructive Surgery of
the Eye and Adnexa
Basic and Clinical
Pharmacology
Bertram Katzung, M.D., (ed). Los
Altos, CA Lange Medical Publi-
:ations, 1984. Pp. 888. Illustrated.
$26)
Basic and Clinical Pharmacology
s an excellent, concise textbook of
Dharmacology for students of medi-
cine and related health sciences.
Sach chapter is authored by individ-
uals with expertise in the area
Altogether, 63 individuals have
contributed to this volume, but the
editor, a professor of pharmacology
at the University of California San
Francisco, has attained far greater
clarity and uniformity of style than
are found in many multiauthored
texts.
The orientation of facts and con-
cepts presented is unmistakably
clinical and is commonly organized
3n the basis of clinical uses rather
than molecular mechanism of ac-
tion. Often, chapters attempt to ex-
plain the rationale for therapy by re-
lating the molecular actions of drugs
to our current understanding of the
pathophysiological basis of disease.
The initial three chapters, which
provide information about drug re-
ceptors, pharmacodynamics, and
pharmacokinetics, notably are excel-
lent in explaining contemporary
concepts in a manner suitable for
medical students. While reasonably
complete and current, the infor-
mation presented is not encyclo-
pedic in scope and tends to
emphasize central facts and con-
cepts. This provides a text of man-
ageable dimensions for an introduc-
tory course in pharmacology rather
than an exhaustive reference com-
pendium.
Bibliographies provided at the end
of the chapter are thoughtfully
selected, recent, and commonly
provide good guidance to those seek-
ing additional information on a par-
ticular topic. Useful appendices
summarize important drug inter-
actions, drug effects on laboratory
tests, and trade name-generic name
identities.
Bruce McL. Brecken ridge,
M.D., Ph.D.
Current Medical
Diagnosis and
Treatment — 1 984
Marcus A. Krupp, M.D., and Milton
J. Chatton, M.D. (eds). Los Altos, CA,
Lange Medical Publications, 1984.
Pp. 1.153. ($26)
This book has become a standard
item on the bookcase behind the
doctor’s desk. There must be several
times a week we must look up a vital
point quickly as the patient in ques-
tion is waiting in our office.
The text has 34 chapters covering
the entire field of medicine and a
very good index enabling one to
quickly find the topic of interest.
The book is useful for a quick review
of a subject in order to find the
answer to one or two questions, i.e.
what is the best antibiotic for otitis
media in an adult; what are the key
features of AIDS; and which is the
best prophylactic medication
against diarrhea for a traveler going
to Mexico.
The book is reissued annually and
written by respected experts. Many
readers will disagree with points of
the book because the authors strive
for extreme terseness and simple
facts while medical subjects often
are confusing and “facts” doubtful.
A small bibliography follows each
topic subject and the interested
reader can delve more deeply and
reach his or her own conclusion
among the many choices. This re-
viewer recommends this book for
purchase and frequent use.
Norman Riegel, M.D.
Current
Gastroenterology ,
Volume 4
Gary Gitnick (ed). New York, NY,
John Wiley & Sons, 1984. Pp. 461.
Illustrated. ($60)
This book represents the editor’s
fifth annual review of progress in
gastroenterology. The first year’s vol-
ume combined hepatology and
gastroenterology— this now has
been split into separate reviews enti-
tled Current Hepatology and Cur-
rent Gastroenterology.
This text is a multiauthored litera-
ture review and, therefore, the con-
tents of the nine separate chapters
risk reflecting the personal preju-
dices of the chapter author. Each
chapter has been reviewed not only
by the editor but also by an expert
in the field, who advises the chapter
author on errors of omission or un-
balanced views. The authors are
charged with selecting the most sig-
nificant report from the literature
and assessing areas of progress or
change. The aim is to include im-
portant articles that further our
understanding of the workings of
the particular organ and help us to
deal with the disorders of this organ
as scientists and clinicians.
By and large, this aim has been
achieved. The chapter authors will
be well recognized by gastroen-
terologists as respected experts in
their various fields. In fact, this very
well may be the best review of
gastroenterology that I have come
across in quite some time. The book
is aimed specifically for those with
a solid background in gastroenter-
ology. However, it will also be useful
for someone interested in a brief up-
date of a particular topic which is
well referenced.
The book is divided into nine sec-
tions beginning with the traditional
chapters on the esophagus, stom-
ach, small intestine, colon, and pan-
creas. This is followed by sections on
gastrointestinal hormones and
gastrointestinal malignancies. The
next chapter is interestingly con-
cerned with extraintestinal mani-
festations of gastrointestinal dis-
ease and gastrointestinal mani-
festations of extraintestinal disease.
Finally, the chapter on advances in
gastrointestinal endoscopy is both
appropriate and appreciated.
I found reading this text both
VOL. 81— NUMBER 12— DECEMBER 1984
1 103
pleasurable and practical. Certainly,
some chapters have more clinical
relevance than others. I recommend
this book to all my colleagues in
gastroenterology and anyone else
with an interest or background in
this area.
Joel D. Levinson, M.D.
Merritt’s Textbook of
Neurology ,
Seventh Edition
Lewis P. Rowland, M.D., (ed). Phila-
delphia, PA Lea & Febiger, 1984.
Pp. 774. Illustrated. ($48.50)
Dr. H. Houston Merritt first pub-
lished this text in 1955 and then
was the sole author. It has been a
standard neurology text for three
decades. Dr. Merritt remained its
only author until the sixth edition
when he accepted some limited con-
tributions by others. He died in
1979. His current successor as di-
rector of the neurology service at the
Neurological Institute of Presby-
terian Hospital, New York City, Dr.
Lewis P. Rowland, now has as-
sembled some 70 authors to compile
this latest edition. Most of them
were former students of the original
author.
Much of Dr. Merritt’s material re-
mains, but the contributors have
updated and added new material in
many areas. One entirely new fea-
ture is an opening segment of 50
pages devoted to the description of
symptoms of neurologic disorders
such as headache, coma dementia
weakness, and involuntary move-
ments. That section will be most
useful to students and house of-
ficers, but all physicians will profit
by reading it.
The editor has woven the con-
tributions into a very uniform fabric
that is both complete and com-
prehensive. The effort to preserve
Merritt’s clear, simple, and lucid
style of writing is successful, though
some sentences are quite long and
complex. One minor detraction is
the relatively small print size, per-
haps utilized to limit the overall size
of the book. Presentation of this
wealth of material flows smoothly,
but is so extensive that probably few
will read through the complete text
except for beginning neurology resi-
dents. References are recent, ap-
propriate, and kept to a reasonable
number. Indexing is extensive and
very usable. And, the cost of the text
certainly is reasonable by today’s
standards.
Interns, residents, general phy-
sicians, and neurologists all will find
this latest edition of a familiar text
both a bargain and very useful in its
new format. The late Dr. Merritt
would be very proud indeed of this
edition.
Stanley C. Leonberg Jr., M.D.
The Source Book of
Plastic Surgery
Frank McDowell, M.D., (ed). Balti-
more, MD, Williams & Wilkins,
1977. Pp. 509. Illustrated. ($50.95)
The Source Book gives a historical
review of the beginnings of plastic
surgery. It includes many original
articles translated by distinguished
modem plastic surgeons and others.
The “linkage” of one historic publi-
cation to another has been done ex-
pertly with the use of editorial com-
ments and short descriptions of the
original authors.
Some emphasis has been placed
on the history of rhinoplasties and
the repair of cleft lip and palate.
However, since most of the dis-
tinguished originators of the re-
constructive procedures were out-
standing general surgeons and
physicians, this book should be of
interest to all. Biographies of some
of the great builders in the field of
plastic surgery have been included
at the end.
Dr. McDowell, a well-known sur-
geon and for many years editor of
the American Journal of Plasr.
and Reconstructive Surgery, has i|
constructed a most valuable boo
that will be an addition to every sc
geon’s library and a must for eve
plastic surgeon.
Robby Meijer, M.
Third International
Symposium of Plastic
and Reconstructive
Surgery of the Eye and
Adnexa
Aston, Homblass, Meltzer, Ree
(eds). Baltimore, MD, Williams J
Wilkins, 1982. Pp. 362. Illustratei
($68)
The Third International Syn
posium of Plastic and Reconstnu
tive Surgery of the Eye andAdnexi
is an authoritative and completi
text on the subject of ophthalmi
plastic and reconstructive surgerj
that should appeal to a very wid<
range of specialists and sub!
specialists; this includes genera!
plastic surgeons, ophthalmologists
ear, nose, and throat surgeons
dermatologists, oral surgeons, anc
neurosurgeons.
The book is well organized anc
consists of excellent articles by rec
ognized experts in their field. The
subjects covered are of interest to al
subspecialists, yet are combined in
one text in detail. All of the sections
are well written, informative, and
worthwhile, but the section “Con
genital Deformity of the Orbital Re-
gion” is particularly outstanding.
The sections ‘Tumors of the Orbit,"
“Lacrimal Disorders," “Soft Tissue
Sockets,” and “Ptosis” are not as
strong.
This text is strongly recommend-
ed as a reference source for any of
the subspecialists who encounter
patients with various problems in
ophthalmic plastic and reconstruc-
tive surgery.
Joseph A. Mauriello, Jr., M.D.
1104
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
IBITUARTES
Drs. Branigan ; Frost;
Gardner; Moeckel;
Rosamilia; Silverman;
Winter
I
»r. G.V. Branigan, Jr.
George Velesto Branigan, Jr., M.D.,
irmer director of the department of
"thopedic surgery at Valley Hospi-
d, Ridgewood, died on August 22,
384. Bom in 1924, Dr. Branigan
;ceived his medical degree from
eorgetown University School of
ledicine, Washington, D.C., in 1948.
ifter completing an internship at
eterans Administration Hospital,
rooklyn. Dr. Branigan started a pri-
ate orthopedic practice in Oakland
i 1950; after serving in the Korean
far, he moved his office to Ridge-
ood in 1960. Dr. Branigan was af-
liated with Ridgewood Hospital for
3 years; he also served on the staff
if Paterson General Hospital. A
lember of our Passiac County com-
onent and of the American Dental
ssociation. Dr. Branigan was a
I'iplomate of the American Board of
jrthopedic Surgery and a Fellow of
le American College of Surgeiy.
>r. Inglis F. Frost
At the grand age of 96, Inglis
olger Frost, M.D., died on July 27,
984. Bom in New York, Dr. Frost
eceived his medical degree from
ale Medical School in 1912. After
an internship at Lenox Hill Hospital,
New York, he opened his own prac-
tice in New York City. In 1919, Dr.
Frost moved to Morristown, where
he practiced until his retirement in
1959. During his lengthy career, he
was affiliated with Riverside Hospi-
tal, Boonton; General Hospital,
Dover; St. Clare Hospital, Denville;
and Memorial Hospital, Morristown.
In 1933, Dr. Frost served as presi-
dent of the Morris County Medical
Society and in 1964, he served as
president of the New Jersey Ob-
stetrical and Gynecological Society.
Dr. Frost was a recipient of MSNJ’s
Golden Merit Award in 1962, in rec-
ognition of 50 years of medical prac-
tice. Dr. Frost was a retired member
of our Morris County component, a
Fellow of the American College of
Obstetricians and Gynecologists
and of the American College of Sur-
geons, and a member of the Ameri-
can Medical Association.
Dr. Kenneth E. Gardner
Kenneth Earl Gardner, M.D., the
166th President of the Medical So-
ciety of New Jersey, died on Septem-
ber 12, 1984, at the age of 81. Dr.
Gardner, a family practitioner from
Bloomfield, served the medical com-
munity for over 50 years; during his
lengthy career he was affiliated with
The Mountainside Hospital,
Montclair. Dr. Gardner earned his
medical degree from the University
of Pennsylvania Medical School in
1930 and completed postgraduate
work at Philadelphia General Hospi-
tal and Columbia University. A Fel-
low of the American College of Chest
Physicians, Dr. Gardner was a re-
tired member of our Essex County
component, and a member of the
American Medical Association. Dr.
Gardner served the Medical Society
as a judicial councilor, and chair-
man of the subcommittee on public
health and of the welfare committee.
In 1980, Dr. Gardner received
MSNJ’s Golden Merit Award in rec-
ognition of his 50 years as a phy-
sician.
Dr. C. William Moeckel
Clarence William Moeckel, M.D.,
died in April 1984. Bom in 1904, Dr.
Moeckel earned his medical degree
at Tufts University School of Medi-
cine. Massachusetts, in 1928. A gen-
eral surgeon. Dr. Moeckel was af-
filiated with The Mountainside Hos-
pital, Montclair. He was a retired
member of our Essex County com-
ponent, a member of the American
Medical Association, and a Fellow of
the American College of Surgery.
Dr. Ralph E. Rosamilia
Ralph Elmer Rosamilia, M.D., chief
of surgeiy at Clara Maass Medical
Center, Belleville, from 1961 to 1971,
died on July 27, 1984. Bom in New-
ark in 1906, Dr. Rosamilia earned a
medical degree from Syracuse Uni-
versity Medical School, New York, in
1932. He maintained a practice in
Newark for 42 years, retiring in
1976. Dr. Rosamilia was a retired
member of our Essex County com-
ponent. In 1982, Dr. Rosamilia re-
ceived MSNJ’s Golden Merit Award
honoring his 50 years as a phy-
sician.
Dr. T.M. Silverman
At the age of 92, Theodore M. Sil-
verman, M.D., died on September 9,
1984. Bom in New York City, Dr. Sil-
verman completed his medical
education at the University of Geor-
gia Medical School in 1920. He
moved to New Jersey a few years
later and was affiliated with St.
Elizabeth Hospital and Alexian
Brothers Hospital, both in Elizabeth.
Dr. Silverman was a retired member
of our Somerville County compo-
nent, a member of the American
Medical Association, and a Fellow of
the American Academy of Family
Practice.
Dr. Egon W. Winter
At the age of 8 1 , Egon Werner Win-
ter, M.D., died at home on August 24,
1984. Dr. Winter was a 1925 gradu-
ate of the University of Geisen Medi-
cal School, Germany. He emigrated
to the United States in 1938 and
opened a practice in Maplewood,
where he served the community for
20 years. An obstetrician-gynecolo-
gist, Dr. Winter was affiliated with
Saint Barnabas Medical Center. Liv-
ingston, and Newark Beth Israel
Medical Center. Dr. Winter was a
member of our Essex County com-
ponent and of the American Medical
Association, a Diplomate of the
American Board of Obstetrics and
Gynecology, and a Fellow of the
American College of Surgeons and of
the International College of Sur-
geons.
'OL. 81— NUMBER 12— DECEMBER 1984
1 105
MSNJ Members . . .
rhere has never been a better time to improve your Keogh and Corporate Retirement Plans
Health Care Consulting, Inc. (HCC), primary
affiliate of THE HEALTH CARE GROUP, and
he Medical Society of New Jersey introduce
t timely program for individually designed
etirement plans —
— drafted exclusively for physicians'
practice needs
— containing more than 30 comprehen-
sive, frequently overlooked features
invaluable to medical practices
— complying with TEFRA as you must in 1984
— allowing the same physicians directed
investment choices for incorporated and
unincorporated practices
— and providing innovative Ongoing Plan
Service — accessibility to consultation and
advice, routine amendments and our
exclusive Retirement Planning Newsletter
, MbDICAL
SQCiety
OF NEW JERSEY
_
€ar Fell° w Member: September, i g84
?*sSS$
fZT iner " ^ must « 1984
ftures des^ m
Health ~ descriptive wembe
Plans TmT WW find materials Urn , ^
Umely Informative as v„
°° you evaluate your retirement
HEM:gsl
Enclosure
Sincerely ,
Chairman cl M'D-
1984 is a pivotal year for retirement planning, with the challenges presented by TEFRA and the
opportunity for individually drafted plans. ~
HCC is extremely pleased to work with MSNJ and has prepared informative material on
“retirement planning under TEFRA," “comprehensive plan features," and a “checklist to review
your plans," available by phoning toll-free or writing —
Health Care Group
Vledical Society of New Jersey/
Health Care Consulting, Inc.
z/o THE HEALTH CARE GROUP
One Belmont Avenue
Bala Cynwyd, PA 19004
1-800-441-0737
;215) 667-2468
Name _
Address
Phone
Unincorporated □ Incorporated □ Fiscal year ends
1106
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Index: Volume 8i
January to December 1984
Published monthly under the direction of the Committee on Publication
Paul J. Hirsch, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
La Verne Fioretti
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
Arthur Krosnick, M.D., Editor
Geraldine R. Hutner, Managing Editor
Dorothy J. Griffith, Assistant Managing Editor
Editorial Office
Two Princess Road
Lawrenceville , NJ 08648
Society established July 23, 1766
The Journal founded September 1, 1904
70L. 81— NUMBER 12— DECEMBER 1984
1 107
ACKNOWLEDGEMENTS
The Journal acknowledges the contributions of the
members of the Editorial Board (whose names are
listed on the title page of each issue) for their as-
sistance in evaluating scientific manuscripts. Th
Journal also wishes to thank the following Ad Ho
Reviewers and Book Reviewers for 1984:
AD
Herman Baker, Ph.D.
Salvatore Bongiovanni, M.D.
James E. George, M.D., J.D.
Robert A. Goldstone, M.D.
Bernard Grossman, M.D.
Murray Kahn, M.D.
Sidney Ketyer, M.D.
BOOK
Jerome Abrams, M.D.
James W. Allen, M.D.
Joseph Alpert, M.D.
Herman Baker, Ph.D.
Bruce McL. Breckenridge, M.D., Ph.D.
Solomon J. Cohen, M.D.
Samuel E. Einhom, M.D.
Jay Eldredge, M.D.
James E. George, M.D., J.D.
Robert A. Goldstone, M.D.
Ralph S. Greco, M.D.
Gerard F. Hansen, M.D.
Christine E. Haycock, M.D.
Neil B. Homer, M.D.
Murray Kahn, M.D.
Jack R Karel, M.D.
Avrum L. Katcher, M.D.
Sidney Ketyer, M.D.
J.F.J. Leyson, M.D.
Stanley C. Leonberg, Jr., M.D.
REVIEWERS
Bernard J. Koven, M.D.
Russell L. McIntyre, Th.D.
Michael L. Mund, M.D.
Peter E. Nathan, Ph.D.
Michael A. Nevins, M.D.
Max M. Novich, M.D.
James S. Todd, M.D.
REVIEWERS
Joel D. Levinson, M.D.
Hugh F. Luddecke, M.D.
Robert M. MacMillan, M.D.
John S. Madara, M.D.
Dominic A. Mauriello, M.D.
Joseph A. Mauriello, Jr., M.D.
Robby Meijer, M.D.
Michael A. Nevins, M.D.
Christopher A Papa, M.D.
Joseph Peyser, M.D.
Hany M. Poppick, M.D.
T.K. Rathmell, M.D.
Norman Riegel, M.D.
Edwin L. Rothfeld, M.D.
Manuel A Rowen, M.D.
Mark M. Singer, M.D.
Leon G. Smith, M.D.
Robert K. Spiro, M.D.
Wemer Steinberg, M.D.
Frank C. Vanore, M.D.
TABLE OF PAGES
January
February
March ...
April
May
June
1- 88 July 527- 612
89-160 August 613- 690
161-256 September 691- 822
257-352 October 823- 912
353-440 November 913-1012
441-526 December 1013-1122
KEY
*— Article
br— Book review
cr— Case report
cn — Clinical note
cm— Commentary
ed — Editorial
ip— Impaired physicians
le— Letter to the editor
+— Obituary
op — Opinion
ra— Review article
sp— Special article
sa— State of the art article
1108
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
'Abel, Henri E„ M.D +685
Academy of Medicine Awards ed541
Academy of Medicine of New Jersey:
A Brief History— Saffron *785
Academy of Medicine of New Jersey Report—
Hirsch 71, 145. 238, 330, 424, 511, 980
Acute Radiation Pneumonitis— Silberstein; Malcolm;
Braun; Fayemi cr49
t Actinomycosis— Baker Ie995
Acutely 111 Elderly. The — Joel *655
Adverse Drug Reaction after Administration of
Influenza Vaccine — Solomon; Morlino;
Martucci; Ney cn573
Aesthetic Breast Surgery— Greco br344
Affuso, Philip S„ M.D cr43
Agarwal, Shashi K, M.D *110, cr211
AIDS, Blood Banks and edl05
AIDS. Effects of, on Various Aspects of Blood
Banking — Kuriyan; Muschenheim; Bianco *875
AIDS?, May a Blood Bank Refuse Donations To
Prevent the Spread of— Smith; Brennan;
McDonough *125
Alabama Granny Midwife— Holmes mh389
Alcoholic Cardiomyopathy — GAsp&r cr557
lAlewitz, Sam, Ph.D *740
Alexander, Samuel, M.D., and the Uniform Medical
Practice Act — Alexander *759
Alexander, Stewart F„ M.D *661, *759
Allen, James W„ M.D *377
Altin, Robert S., M.D cr217
Alzheimer's Disease: The Standard Reference
Book — Poppick br904
AMA Principles of Medical Ethics sa31
Amniocentesis for Prenatal Diagnosis,
Midtrimester— Ghiatas *867
Amyloidosis— Varga Ie248
Amyloidosis and Idiopathic Hypertrophic Subaortic
Stenosis, Cardiac— Daniels; Weinberg;
Rangwala Mintz *481
Androgen-Secreting Ovarian Tumors in
Postmenopausal Women— Ober *878
Anesthesiologist, Professional Liability and the 285
Aneurysm of the Descending Thoracic Aorta—
Agarwal; Haft; Bachik cr2 1 1
Aneurysm, Tracheoesophageal Fistula and
Arteriosclerotic Aortic — Schiffman cr563
Annual Meeting btl44, bt235, bt328
Annual Review of Neuroscience, Volume 7—
Leonberg br605
Annual Review of Nutrition, Volume 3— Baker br605
Anson, Leon J.. M.D Ie903, +906
Anthony, David W„ M.D +251
Anticonvulsant Agents— Geller 322
Antinori, C.H., M.D cr393
Aorta Aneurysm of the Descending Thoracic —
Agarwal; Haft; Bachik cr211
Aortic and Mitral Valve Replacement, Part 1 —
Olivieri; Kostis *949
Aortic and Mitral Valve Replacement Part 2—
Olivieri; Kostis *1055
Area Health Education Center Program, The— Landay;
Cohen; Reynolds *37
Arthroscopy: Diagnosis and Surgical Practice—
Goldstone br605
Aspiration in Metastatic Malignant Melanoma
Fine-Needle— Rothman; Olaizola Baker crl35
: \Atlas of Human Cross-Sectional Anatomy —
Peyser br683
Autopsies at Newark City Hospital, 1908-1911 —
Sharpe mh53
Auxiliary, President of MSNJ 475
Azzara Emanuel S., M.D +435
■—
Baby Doe — Brogan
Baby Doe and Prognosis Committee — Katcher
I,
le517
edl06
Bachik, Michael, M.D cr211
Bachmann, Gloria A, M.D *857
Baker, John, C.T crl35
Banting, The Art of — Krosnick mhl38
Banting, Sir Frederick G.— The Artist edl05
Barach, Richard L., M.D +906
Barber, George E„ M.D +82
Bart, Kenneth J., M.D *887
Basic and Clinical Endocrinology — Singer br249
Basic and Clinical Pharmacology — Breckenridge
brll03
Basic, Joan: Executive Secretaiy— Willis Ie995
Benefits, Assignment of bt997
Benign Neglect Whatever Happened to?— Nevins ... cm222
Bergen, Stanley S., Jr., M.D., Newark 70, *791
Bemardin, Ronald Maurice, M.D +1005
Bernhard, Joel A, M.D +607
Bernstein, Ellen H„ M.D +435
Bianco, Celso, M.D *875
Bimbaum, Leo, M.D +607
Births: A Survey of Patients, Out-of-Hospital—
Gregory; McDonough; Maciorowski; Miller *549
Block, Paul J„ M.D +435
Blood Banks and AIDS edl05
Bochenek Joseph P„ M.D +520
Book Reviews 83, 155, 249, 344, 433, 518,
605, 683, 904, 996, 1103
Brain, Microsurgical Resection of AV Malformations
from Vital Areas of the — Hubschmann;
Krieger *870
Brain-Damaged Persons, Rehabilitation of Cognitive
Function in — Pollack; Kohn; Miller *311
Brandeis, V.T., M.D *849
Branigan, G.V., Jr., M.D +1105
Braun, Evalynne V., M.D cr49
Breast Cancer, Alternative Treatment— Seltzer lei 53
Breast Cancer: Diagnosis and Management
Volume 1 — Abrams br996
Brennan, Richard, LL.D *125
Brodman, Estelle, Ph.D *779
Brostrom, Margaret A, Ph.D *967
Bowers, Roy A, Ph.D *765
Buckley, Jeremiah L., M.D +520
Bump, S. Calthrop, M.D +685
Burstein, Allan, M.D *863
Byck Louis, M.D +685
c
Camden, The Life and Times of— Alewitz *740
Camejo, Rafael, M.D +1005
Canavan, David I„ M.D ip65, ip 140, ip507
Cancer Control Coordinating Council bt235
Cancer, Impact of, on Patient and Family,
The Psychological— Singer *383
Carcinoma in Children, Infantile Embryonal —
Affuso; Fayemi cr43
Carcinoma Peroral Esophageal Endoprosthesis for
the Management of Incurable— Kalkay:
Pancen Derman cr45
Cardiac Amyloidosis and Idiopathic Hypertrophic
Subaortic Stenosis— Daniels; Weinberg;
Rangwala Mintz *481
Cardiomyopathy, Alcoholic — G&sp&r cr557
Carr, Josephus C„ M.D +1005
Carras, Peter D„ M.D +1005
Cassidy, Herbert E„ M.D +906
Ceftriaxone, A Third Generation Cephalosporin—
Johnson; Fedder; Smith *941
Cenizal, Jesus, M.D crl31
Cephalosporin, Ceftriaxone, A Third Generation —
Johnson; Fedder; Smith *941
Certificate of Need bt997
Chairman of the Board of Trustees bt589
Challenge of the Geriatric Imperative— Nevins ed631
Chanin, Israel L„ M.D +251
Chico, Christine, D.O *798
Child Find— Stromsland Ie604
Chinard, Francis, M.D *661
vDL. 81— NUMBER 12— DECEMBER 1984
1 109
Chiropractic Practice bt509
Chiropractic, State Board Committee on bt893
Choi, Jay Jong-11, M.D cn569
Cholankeril, John V., M.D crl31
Cholecystitis, Imaging: An Approach to the
Diagnosis of— Zeiger *411
Cinotti, Alfonse A, M.D ed632
Classics of Cardiology, Volume 3— MacMillan br996
Clinical Gastroenterology: A Problem-Oriented
Approach — Riegel br83
Clinical Nuclear Medicine — Homer br433
Clinician's Approach to Endocrine Problems:
45 Case Studies— Singer br683
CME Calendar 77, 149, 241, 337, 429, 515,
597, 677, 899, 991, 1099
CME Information 597
Cognitive Function in Brain-Damaged Persons —
Pollack *311
Cohen, Benjamin L„ D.O *37
Cohen, Sidney L., M.D +154
Colburn, Daniel W„ M.D *849
Colitis, Radiographic Findings in Pseudomembranous—
Altin cr217
Color Atlas of Life before Birth — Steinberg brl55
Color Atlas of Diabetes, A— Einhom br605
Common Skin Disorders, 2nd Edition— Papa br344
Compulsive Gambling: Your Assemblyman
Speaks— Hardwick *1046
Computer System, Selection of a Medical Office-
Alien *377
Computerized Tomography-Guided Percutaneous
Needle Biopsy— Jewel *297
Computerizing Your Medical Office: A Guide for
Physicians and Their Staff— Allen br433
Conroy Case, The— Rothberg cm229
Controversies in Dermatology — Kahn br683
Conversations in Medicine — Weisse mh576
Coronary Artery Disease in Infants and Children—
Eldredge brl55
Corporate Practice of Medicine bt423
Corporate Restructuring of New Jersey Hospitals .... bt509
Cost of Health Care, The— Courier 669
Cost of Medical Care hg465
Courier, Jim 669
Cowen, David L., MA, Litt.D *807
Crystal, Raymond F„ M.D *959
Current Emergency Diagnosis and Treatment—
Karel brl55
Current Gastroenterology, Volume 4 — Levinson brll03
Current Legislation 1089
Current Medical Diagnosis and Treatment 1984 —
Riegel brll03
Current Pediatric Diagnosis and Treatment
8th Edition — Cohen br904
Current Surgical Diagnosis and Treatment
6th Edition— Spiro br83
Current Therapy in Obstetrics and Gynecology II—
Hansen br433
■ D—
D’Agostin, Henry, M.D +1105
Daniels, Richard A, M.D *481
Death, Pronouncement of bt589
Deaths Related to Narcotics Overdose in New Jersey —
Feuer; French *291
Delisi, AM., M.D *849
Demographic Study of Membership btl43
Derm an, Arnold, M.D cr45
Deuell, William D„ M.D +520
DeVivo, John A, M.D +685
Diabetes: A New and Complete Guide to Healthier
Living — Einhom br344
Diagnostic Virology Laboratory Report — Michalski 425
Dialysis for End-Stage Renal Disease— Walken
Dodelson; Eisinger *1067
Dickinson, George W„ M.D +685
Disorders of the Hip — Goldstone br344
Dodelson, Robert, M.D *1067
Donnelly, John H„ M.D +341
Dopamine Receptors, Pharmacological Basis of
Therapeutics— Heikkila *108
DRG: New Jersey and the Federal System—
Rineberg cm40li
DRG Position bt50!
DRG Waivers bt235, bt89;
DRGs: Two Viewpoints— Maressa; Rubacky Ie68
DRGs: Update of— Johnson cm89
Dropping the Ball: Tennis, Golf, and Alcohol —
Van Ost edl8
Drossner, Jacob L., M.D +607
Dues Discount for Medical School Faculty btl4C
Effects of AIDS on Various Aspects of Blood
Banking— Kuriyan; Muschenheim; Bianco *875
Eicosanoids— Mediators of Biological Functions—
Wolff 507
Eisinger, Robert P„ M.D *1067
Elective Offices of MSNJ bt32/i-
Electrocardiogram in Infants and Children:
A Systemic Approach. The— MacMillan br515
Emergency Medicine— Karel br24£
Endoprosthesis for the Management of Incurable
Esophageal Carcinoma, Peroral
Esophageal— Kalkay; Pancer; Derman cr4E
Esposito, Joseph I„ M.D +251
Essertier, H.C., M.D +346
Ethics, AMA Principles of Medical sa31
Evaluation and Decision Making for Health
Services Programs— Madara br519
Evaluation of the Suicidal Adolescent Patient
Admitted to an Urban Hospital— Pierog; Hill ... *197
Extra-Anatomic Bypasses in Aortoenteric Fistulas—
Antinori; Kain; Kuchler; Manuele;
Pierucci; Villanueva cr393
E)ye Health Screening Week— Cinotti ed632
E^ye Screening Coordinating Council bt893
— — F
Familial Dysalbuminemic Hyperthyroxinemia
A Variant— Goldman; Iflinges cr404
Farmer, Walter D„ M.D +435
Farrer, William E„ M.D cr317
Fayemi, A Olusegun, M.D cr43, cr49
Fedder, Marc, M.D *941
Fee Freeze bt893
Fee Freeze, Medicare bt997
Ferrary, Paul B., M.D +154
Fertilization in New Jersey: Initial Experience
with In Vitro— Kemmann; Colburn;
Pasquale; Nosher; Brandeis; Delisi;
Shelden *849
Fetal Alcohol Syndrome, Task Force on 146
Feuer, Elizabeth, M.D *291
Fickeissen, Janet L„ RN *805
Filippone, Dennis R, M.D 331
Finance and Budget Committee on bt510
Fine-Needle Aspiration in Metastatic Malignant
Melanoma — Rothman; Olaizola; Baker crl35
Finkel, Jerrold S„ M.D +1005
First Clinical Year of Medical School, The—
Kranzlen Vitting; Reynolds *113
Fischer, Alvin L„ M.D +685
Fistulas, Extra-Anatomic Bypasses in Aortoenteric—
Antinori; Kain; Kuchler; Manuele;
Pierucci; Villanueva cr393
Fitzpatrick, Thomas P *701
Flashback, FUsks Associated with Post-traumatic—
Burstein *863
Frank, Perry, M.D +520
Frantantuno, M.J., M.D +346
Franz Ronald L., M.D +906
French, John, MA *291
Frost Inglis F„ M.D +1105
Fulcrums and Forums, and Clout — Bourns Ie681
1110
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
Fundamentals of Family Medicine— Peyser br249
Fundamentals of Immunology, 2nd Edition—
Luddecke br519
— — G -—■■■«
Gambling, New Jersey Initiates Steps To Combat
Compulsive— Klein *1051
Gardam, Joseph W„ M.D +685
Gardner, Kenneth E„ M.D +1105
Gcispcir, Istvdn A, M.D cr557
Geller, Herbert M„ Ph.D 322
Gellman, Mrs. William B 475
Geriatric Assessment Programs— Rubenstein *651
I Geriatric Imperative *637
Ghlatas, Abraham, M.D *867
Gilbert, Donald K. M.D +346
Glasgold, Alvin I., M.D *187
Glick, Bernard, M.D +520
Golden Merit Awards 476
Goldman, Michael H„ M.D cr404, cr501
Goldstein, Herman H„ M.D +82
Goldstein, Jonathan, M.D *110
Good, Charles K, M.D +686
Gossypol, An Oral Male Contraceptive— Penningroth . 663
Gotsch, Audrey R, Ph.D *493
Greenfield, Arthur W„ M.D +435
Gregory, Margaret, M.D *549, *935
Grieco, Emil H„ M.D +906
Gross, Arthur F„ M.D +251
Grossman, Bernard, M.D op421
Guide to Cardiology, The — Rowen br684
Guided Blind Endotracheal Intubation— Choi;
Potian; Yoo; Wu cn569
Guthom, Peter J„ M.D *769
H
Haft, Jacob, M.D *110, *211
Hall, Perry O., M.D +154
Halperin, David, M.D +251
Handbook of Pediatric Primary Care, 2nd Edition—
Vanore br996
Hansen, Gerard F„ M.D *935
Hardwick, Chuck *1046
Harrington, John H„ M.D +520
Harris, Edward, M.D *661
Haycock, Christine E„ M.D *773
Health and Human Values: A Guide to Making
Your Own Decisions — Nevins brll03
Health Care Facilities Planning Act bt894
Health Care Facility Committee, Blue Ribbon
Ad Hoc btl43
Heart Multiple Imaging Procedures— Ketyer br83
Hebble, Judy *493
Heikkila, Richard E„ Ph.D *1084
Hely, Charles J„ M.D +1005
Henderson, George T„ M.D +251
Hermann, John H„ M.D +435
Hill, Austin, Ph.D *197
Hill, Clarence T„ M.D +607
Hinman, Alan R, M.D *899
Hirsch, Paul J„ M.D 71, 145, 238, 330, 424, 511, 980
Historiography, 1964-1984, New Jersey Medical—
Cowen *807
History of Medicine and Medical Care in
New Brunswick, The— Reitman *737
I Hitzemann, Luis A, M.D +686
HMO Advertising bt589
Holmes, Linda, M.PA mh389
Horowitz, Susan B„ Ph.D *187
Hospital Association, The History of the
New Jersey— Staab *802
Hospital Governing Boards 21, 107, 185, 283, 465,
545, 635, 847, 931, 1045
Hospital Medical Staff Section bt423
Hubschmann, Otakar R, M.D *870
Hydatid Disease of the Liver— Kessler, Ketyen
Cholankerll; Cenizal crl31
Hymowitz, Norman, Ph.D *487
Hyperprolactinemia in a Patient with
Pseudotumor Cerebri— Goldman; Rabin cr501
Hypertensive Patients; Promoting Compliance in—
Supino; Gotsch; Van Harlingen; Hebble *493
Hyperthyroxinemia- A Variant, Familial
Dysalbuminemic — Goldman; Klinges cr404
I
Illustrated Computer Tomography: A Practical
Guide to CT Interpretations— Homer br433
Illustrated Textbook of Gynaecology— Hansen br904
Imaging; An Approach to the Diagnosis
of Cholecystitis— Zeiger *411
Imaging, Indium- 1 1 1-Oxine- Labeled Leukocyte-
Palace; Crystal *959
Immunizations During Pregnancy — Preblud;
Bart; Hinman *889
Impaired Physicians Program 65, 140, 507, 667
Indium-1 1 1-Oxine- Labeled Leukocyte Imaging-
Palace; Crystal *959
Infantile Embryonal Carcinoma in Children—
Affuso; Fayemi cr43
Initial Experience with In Vitro Fertilization in
New Jersey— Kemmann; Colburn; Pasquale;
Nosher; Brandeis; Delisi; Shelden *849
Insulin-Like Growth Factors, Pharmacological Basis
of Therapeutics— Brostrom *967
Interface between the Acute Hospital and
Long-Term Care, The— Kane; Kennie *643
Intrauterine Testicular Torsion — Rosenberg;
Zimmerman cr320
Intubation, Guided Blind Endotracheal—
Choi; Potian; Yoo; Wu cn569
Is There a Doctor in the House?—
Primich edl041
Is There an Indigenous Viral Flora in Man?—
Michalski *121
J
Jacobus, Raymond E., M.D +520
James, Harold E„ M.D +154
JEMPAC Report 26
JEMPAC Update— Ryan *586
Jewel, Kenneth L„ M.D *297, *884
Joel, Lucille A, Ed.D *655
Johnson, Edward S., M.D *941
Johnson, Martin E cm891
Journal Format, The— Bergen; Sakson Ie517
Journalism, The History of Medical, in New Jersey—
Krosniek *723
Juhasz, Nicholas M„ M.D +686
K
Kain, E.H., M.D cr393
Kalkay, M. Nuri, M.D cr45
Kane, William J„ M.D *643
Karl, Sarah *487
Karshmer, Nathan, M.D +251
Katcher, Avrum L„ M.D edl06
Keates, George H„ M.D +907
Kemmann, E„ M.D *849
Kennie, David C., M.D *643
Kessler, Michael A, M.D crl31
Ketyer, Sidney, M.D crl31
Kilmer, Frederick B„ A Notable New Jersey
Pharmacist— Bowers *765
Klein, Robert M *1051
Kler, Joseph H„ M.D 75, +251
Kline, Oram R, M.D +346
Klinges, Karl, M.D cr404
Kohn, Herbert, Ph.D *311
Koralek, Adolph, H„ M.D +346
Kostant, George H„ M.D +251
Kostis, John, M.D *949, *1055
VOL 81— NUMBER 12— DECEMBER 1984
1111
Kovacs, Alexander, D„ M.D 70, 144, 473
Kranzler, Henry, M.D *113
Kratka, Harold D„ M.D +1006
Krleger, Abbott J., M.D *870
Krosnick, Arthur, M.D mhl38, *723
Kubes, Zdenek, M.D +435
Kuchler, JA, M.D cr393
Kudos to The Journal, Its Staff, and Others ed462
Kuriyan, Mercy, M.D *875
Kustrup, Dr. John F„ M.D., 1907-1984 ed842
L
Ladas, George, M.D +251
Landay, Merwyn A, D.D.S *37
Laquatra, Idamarle *487
LaPorta, Michael L„ M.D +686
Lasker, Norman, M.D *415
Laufenberg, Joseph W„ M.D +907
Law of Medical Practice in Pennsylvania and
New Jersey, The — George br905
Law of the Duck, The— Mlnzter Ie343
Leach, John E„ M.D +607
Legal Services Plan bt509
Legislation, Current 1089
Lenape Contribution to New Jersey
Medicine, The— Fitzpatrick *701
Length of Stay— Dang Ie995
Letters to the Editor 81, 153, 247, 342, 517,
604, 681, 903, 995
Limited Licensed Practitioners bt589
Liver, Hydatid Disease of the — Kessler; Ketyen
Cholankeril; Cenizal crl31
Loigman, Barry I„ M.D *884
M
Macaulay, Francis A, M.D +1006
Maciorowski, Linda RN *549
Magnetic Resonance Imaging (MR1) —
Jewel, Loigman; Mattem; Richman;
Royer Whelan *884
Male Reproduction and Fertility — Leyson br250
Mancene, Edward M„ M.D +607
Mandatory Assignment bt589; le604
Manual of Clinical Gastroenterology — Riegel br83
Manuele, V.J., M.D cr393
Maressa Vincent A, M.D cm409
Marrella Louis F., M.D +82
Martland, Harrison F„ M.D.— Bellet; Berg Ie342; le903
Martucci, Mary, RN cn573
Mass for Physicians— Desmond Ie681
Maternal Deaths in New Jersey, 1982 —
Hansen; Gregory *935
Mattem, Richard R, M.D *884
May A Blood Bank Refuse Donations To Prevent
the Spread of AIDS?— Smith; Brennan;
McDonough *125
McCormack, John L., M.D *190
McCue, John B., M.D +252
McDonough, Brian, J.D *125
McDonough, Robert B„ RN *549
Medicaid Cost Containment bt893
Medical Care, The Rising Cost of ed841
Medical Dynasty in New Jersey, A — Brodman *779
Medical Philately— Kler 75
Medical Staff Standards bt235
Medication Dispensing bt423
Medicine for the Practicing Physician — Poppick br250
Medicine in New Jersey to 1825, A Sketch of—
Saffron *709
Meehan, Martin M„ M.D +82
Melanoma, Fine-Needle Aspiration in Metastatic
Malignant— Rothman; Olaizola; Baker crl35
Meltsner, Louis, M.D +252
Membership Newsletter 7, 94, 167, 265, 359, 449,
532, 619, 829, 919, 1021
Merritt's Textbook oj Neurology, Seventh Edition—
Leonberg brll04
Method of Abdominal Wound Closure, A —
Samson; Schulman; Sabo; Schulman;
Silvers *205
Mettler, Fred A, M.D + 1105
Metzer, Freeman W., M.D +435
Michalski, Frank J„ Ph.D *121, 425
Microsurgical Resection of AV Malformations
from Vital Areas of the Brain—
Hubschmann; Krleger *87(
Midtrimester Amniocentesis for Prenatal
Diagnosis— Ghiatas *867
Milch, Ronald B *647
Miller, Eva, M.S *54£
Miller, Michael H„ Ph.D *31 1
Mintz, Gary, M.D *481
Mitral Valve Replacement Aortic and—
Olivieri; Kostis *949, *1055
Modarelli, Walter H„ M.D +1006
Moeckel, C. William, M.D +1105
Morlino, John, D.O cn573
MSNJ: America’s First and Oldest Medical Society—
Hutner *718
MSNJ Annual Meeting ed543
MSNJ Auxiliary .... 71, 145, 237, 329, 673, 895, 979, 1089
MSNJ News— Via HIN TV edl80
Muschenheim, Frederick, M.D *875,
Myers, Norman V., M.D +686!
Myth or Fact Can Women Self-Diagnose
Pregnancy?— Bachmann *857
'N'
Narcotics Overdose in New Jersey, Deaths Related to—
Feuer; French *291
Nelson's Textbook of Pediatrics, 12th Edition—
Katcher br684
Nevins, Michael A, M.D cm222, *637, *661
New Frontiers in Mammary Pathology — Rathmell . br519
New Jersey Initiates Steps To Combat Compulsive
Gambling — Klein *1051
New Jersey Hospital Association bt68
New Members 71, 330, 511, 673, 895, 1093
Newell, William Augustus, M.D., and the Life
Saving Service— Guthom *769
Ney, Dolores, RN cn573 j
Nobile, James J„ M.D +435
Nominating Committee, Report of 335
Nosher, J., M.D *849
Nuclear Magnetic Resonance (NMR) Imaging-
Homer br434
Nurses’ Association, New Jersey State— Fickeissen .... *805
i
Ober, William B„ M.D *878
Obituaries 82, 154, 251, 346, 435, 520,
607, 685, 906, 1005, 1105
Olaizola, Yayone, M.D crl35
Olivieri, Philip, M.D *949, *1055
Olson, Vendela E„ M.D +520
Opportunity for Change, An— Milch *647
Orthopaedic Society, New Jersey bt997
Osteopathic Medicine in New Jersey, The
First 40 Years— Thompson; Chico *798
Out-of-Hospital Births: A Survey of Patients—
Gregory; McDonough; Maciorowski; Miller *549
Ovarian Tumors in Postmenopausal Women,
Androgen-Secreting— Ober *878
Overcoming Psychic Numbing — Grossman op421
Ownership Statement 988
Pacemaker Therapy— Rothfeld br434
Palace, Fred M„ M.D *959
Pancer, Bernard, M.D cr45
Pancreatic Pseudocyst Associated with Valproic
Acid Therapy — Baskies cr399
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1112
’arvin, Robert W., M.D +1006
’asquale, S„ M.D *849
’atient Care at State Psychiatric Institutions and
Mental Health Centers bt235
'atient Education Program bt589, bt893
’ediatrie Briefs 63, 325, 973
’eer Review Organization btl43
’elosi, Marco A, M.D *303
’enningroth, Stephen M„ Ph.D 663
’eroral Esophageal Endoprosthesis for the
Management of Incurable Esophageal
Carcinoma— Kalkay; Pancer, Derman cr45
’etrosino, Carmen P„ M.D +907
’harmacological Basis of
Therapeutics 322, 503, 663, 967, 1084
’himosis: A Cause of Renal Failure — Rosenberg Ie81
,’hysical Examinations by Nurses bt423
’hysical Therapy and Unlicensed Aides bt509
’hysician Legal Bulletin 285, 623, 1033
’hysicians in the Mouse Trap — Smith ed371
’hysicians Seeking Location in
512, 594, 674, 896, 980, 1094
’ierog, Sophie, M.D *197
’ierucci, L„ Jr., M.D cr393
’neumonitis, Acute Radiation— Silberstein, Malcolm;
Braun; Fayemi cr49
’ollack, Irwin W„ M.D., Piscataway *311
’ollis, Nicholas L„ M.D +1006
’ores, Ira H„ M.D +907
’ostmyocardial Infarction Rupture of the Ventricular
Septum— Agarwal; Haft; Goldstein *110
’otian, Marcelino, M.D., Newark cn569
’orner and the Profession of Obstetrics— Abrams ... br344
tactical Infectious Diseases— Mauriello br250
Tactical Solutions to Common Transfusion
Problems— Taylor 591
’reblud, Stephen R, M.D *889
’regnancy. Immunizations During — Preblud;
Bart; Hinman *889
’regnancy. Myth or Fact: Can Women
Self-Diagnose? — Bachmann *857
’regnancy. Termination of btl088
’remenstrual Syndrome: Fact or Fantasy? Pelosi *303
’rescriptions for Controlled Substances bt235
’resident’s Column — Kovacs 69, 144, 236, 328
’residential Column— Minzter Ie343
’reventing Death from “Hits”— Sugerman ed281
Mmary Prevention of Coronary Heart Disease:
A Practical Guide for the Clinician—
Poppick brl55
’rimich, Frank J„ M.D edl041
’RO bt423, bt510
’rofessional Liability Commentary 13, 99, 175,
276, 365, 456, 537, 629, 837, 923, 1037
Pn ogress in Cardiology, Volume //—Poppick br518
’romoting Compliance in Hypertensive Patients—
Supino; Gotsch; Van Harlingen; Hebble *493
’seudocyst Associated with Valproic Acid Therapy,
Pancreatic — Baskies cr399
’seudotumor Cerebri, Hyperprolactinemia in a
Patient with— Goldman; Rabin cr501
’sychological Effects of Rhinoplasty—
Glasgold; Horowitz *187
’sychological Impact of Cancer on Patient and
Family, The— Singer *383
’ulmonary Edema Complicating Epiglottitis—
Blankson; Scott; Bekes Ie247
Quality of Care Audit of Services bt589
R
labin, Aaron, M.D cr501
ladiographic Findings in Pseudomembranous
Colitis— Altin cr217
Radionuclide Testicular Scanning— McCormack *190
Ramamurti, Suresh, M.D cr317
Rangwala An is F„ M.D *481
Read, Hilton S., M.D +346
Reading, Edward G„ M. Div ip667
Rehabilitation of Cognitive Function in Brain-
Damaged Persons — Pollack; Kohn; Miller *311
Reich, Samuel B„ M.D +521
Reitman, Norman, M.D *737
Renal Disease, Dialysis for End-Stage— Walken
Dodelson; Eisinger *1067
Renal Failure, Diet and Nutrition in Chronic —
Lasker *415
Reorganization of Hospital Staff— Harris Ie342
Retired Lines Reserve 1092
Review of Microbiology — Smith br905
Reynolds, Richard C„ M.D *37, *113
Rhinoplasty, Psychological Effects of— Glasgold;
Horowitz *187
Richman, Steven D„ M.D *884
Rineberg, Bernard A, M.D cm406
Risks Associated With Post-traumatic Flashbacks—
Burstein *863
Rocco, Leo C., M.D +607
Rosamilia Ralph E„ M.D +1105
Rosen, Charles D„ M.D +907
Rosenberg, Joel, M.D *320
Rossi, John R, M.D +907
Rothberg, Harvey, M.D cm229
Rothman, Donald, M.D crl35
Royer, Charles C., M.D *884
Rubenstein, Laurence Z., M.D *651
Rusin, Michael J„ M.D +252
Ryan, William E„ M.D *586
s
Sabo, Jack C., M.D *205
Saffron, Morris H„ M.D *709, *785
Samson, Ian D„ M.D *205
Sandella Joseph F„ M.D +1006
Saul, Maslah, M.D +607
Sawyer, Blackwell, M.D +907
Schefrin, Alexander E., M.D +82
Schiffman, Raymond, M.D cr563
Schulman, Jesse, M.D *205
Schulman, William M„ M.D *205
School, The First Clinical Year of Medical— Kranzler;
Vitting; Reynolds *113
Sciortino, Joseph, M.D +907
SCRAP— Hymowitz; Laquatra Karl *487
Selection of a Blue Cross/Blue Shield Trustee —
Maressa ed463
Selection of a Medical Office Computer System-
Alien *377
Seltzer, Murray H„ M.D lei 53
Septum, Postmyocardial Infarction Rupture of the
Ventricular — Agarwal; Haft; Goldstein *110
Sharpe, William D„ M.D mh53
Shelden, RM *849
Should Community Hospitals Have Geriatric
Units? — Nevins *687
Silberstein, Stuart, M.D cr49
Silverman, Theodore M +1105
Silvers, Lawrence W„ M.D *205
Sims, Eugene W.R, M.D +82
Singer, Barton A, Ph.D *383
Smith, Leon G„ M.D *125, ed371, *941
Smoking Cessation Reduction Act Program, The —
Hymowitz; Laquatra Karl *487
Snape, William J., M.D *731
Social Transformation of American Medicine—
Madara br83
Solomon, Robert, M.D cn573
Source Book of Plastic Surgery, The — Meijer brl 104
Specialty Society Representation bt327
Spivak, David, M.D +907
Spleen, Tuberculous Abscess of the — Farrer;
Ramamurti cr317
/OL. 81— NUMBER 12— DECEMBER 1984
1 1 13
Sports, Committee on Medical Aspects of bt327
Sports Medicine: Health Care for Young Athletes —
Haycock br518
Staab, Linda *802
State Board of Medical Examiners bt68
Stein, Arthur H„ M.D +252
Stein, Steven F„ M.D +346
Stenosis, Cardiac Amyloidosis and Idiopathic
Hypertrophic Subaortic— Daniels; Weinberg;
Rangwala; Mintz *481
Stewart, Irving J„ M.D +521
Stutchin, Abe D„ M.D +435
Subordinated Loan Certificates btl088
Sugerman, A. Arthur, M.D ed281
Suicidal Adolescent Patient Admitted to an Urban
Hospital, Evaluation of the— Pierog; Hill *197
Summary Statement of ACP Study Group— Nevins;
Alexander Chinard; Harris; Wallen *661
Supino, Phyllis, Ed.D *493
T
Tamisiea, John A, Award 896
Taylor, H.L., M.D 591
Technological Basis of Radiation Therapy:
Practical Clinical Applications— Ketyer br684
TEFRA Regulations btl44, bt589
Temporary Vocal Cord Paralysis— Demos Ie247
Testicular Scanning, Ftadionuclide— McCormack *190
Testicular Torsion, Intrauterine— Rosenberg;
Zimmerman cr320
Third International Symposium of Plastic and
Reconstructive Surgery of the Eye and
Adnexa— Mauriello brll04
Thompson, Robert L„ Ed.D *798
Tomography-Guided Percutaneous Needle Biopsy,
Computerized — Jewel *297
Total Mastectomy v Partial Mastectomy and
Radiation Therapy— Cabrera; Schwartz Ie247
Tracheoesophageal Fistula and Arteriosclerotic
Aortic Aneurysm— Schiffman cr563
Transfusion Problems, Practical Solutions to—
Taylor 591
Trustees’ Minutes 68, 143, 235, 327, 425, 509,
589, 893, 977, 1088
Tuberculous Abscess of the Spleen— Farren
Ramamurti cr317
— ■ 1 u—^—
UMDNJ, Medical Education of New Jersey:
The Development of— Bergen *785
UMDNJ Notes 70, 144, 237, 329, 424, 510,
590, 762, 894, 979, 1088
Urgi-Centers bt235
Vaccine, Adverse Drug Reaction After Administration
of Influenza — Solomon; Morlino;
Martucci; Ney cn57.
Van Harlingen, David, Ed.D *49
Van Ost, William C., M.D edl8
Vanderbeek, Stuart W„ M.D +52
Varhol, Joseph G„ M.D +8:
Varicose Veins, Related Diseases and
Schlerotherapy: A Guide for Practitioners—
Alpert br60i
Villanueva, D.T., M.D cr39; t
Vitting, Kevin, M.D *11:1
Vocal Cord Paralysis— Pizzo Ie8
Voss, John C., M.D +68(
iWi
"
Walker, John A., M.D *106'
Wallen, Marven, M.D *66
Walters, George M„ M.D +25:1
Watson, Frank Y„ M.D ed461, 46!
Weems, Don B„ Sr., M.D +8::
Weinberg, Ronald, M.D *48
Weintraub, William L., M.D +8:1
Weisse, Allen B„ M.D mh57(
Whatever Happened to Benign Neglect?— Nevins .... cm22i
Whelan, Charles A., M.D *88^
White, Thomas J„ M.D +68t
Williams, David P„ Jr., M.D +90'!
Williams Issue, Comments on— Kohn Ie681
Williams, William Carlos, A Postscript edl7
Willoughby, Frances L„ M.D +684
Winsten, Sol S., M.D +154]
Winter, Egon W„ M.D +1105
Wolfe, Donald J„ Ph.D 50c
Wolfe, Edward L., Ph.D *731
Women Physicians of New Jersey: The Early Era-
Haycock *773:
Wound Closure, A Method of Abdominal —
Samson; Schulman; Sabo; Schulman;
Silvers *205
Wu, Wen-Hsien, M.D cn569
Yellow Fever During the 18th Century, Preliminary
Report of— Snape; Wolfe
Yoo, Eun Ye, M.D
Youngest Science, The — Madara
*731
cn569!
brl55
Zeiger, Louis S„ M.D 41 lj
Zimmerman, Milton, M.D cr320
1 1 14
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•E-NIGHT PACKAGE
00 PER PERSON, SINGLE OCCUPANCY
00 PER PERSON, DOUBLE OCCUPANCY
,00 PER CHILD SHARING A ROOM WITH PARENTS
-NIGHT PACKAGE
00 PER PERSON, SINGLE OCCUPANCY
00 PER PERSON, DOUBLE OCCUPANCY
00 PER CHILD SHARING A ROOM WITH PARENTS
Forms received after April 1, 1985,
will be confirmed on an “if avail-
able” basis.
Fill out only one form for each room
required.
DEPOSIT OF $100 PER ROOM
MUST ACCOMPANY FORM TO
CONFIRM RESERVATIONS.
Please make check payable to
HOST FARM. Major credit cards ac-
cepted at hotel, but not for deposit.
Hotel confirmation is required for
check-in.
Send form and deposit to:
Host Reservations
2300 Lincoln Highway East
Lancaster, PA 17602
717-299-5500
DK TYPE OF ROOM REQUIRED: □ SINGLE OCCUPANCY □ DOUBLE OCCUPANCY
□ WILL BE SHARING ROOM**
e hotel will not be responsible for assigning roommates. Unless roommate is stated, you will be
assigned a single occupancy accommodation.
iSE PRINT OR TYPE THE FOLLOWING INFORMATION:
E: NO. of CHILDREN: .
MMATES: CHILDREN’S AGES:
1ESS:
slE:
STATE:
ZIP:
;k if official delegate □
YAL DATE DAY
^RTURE DATE DAY
COUNTY:
CHECK-IN: AFTER 4 PM
CHECK-OUT: BY 12 NOON
/IEDICAL SOCIETY OF NEW JERSEY— 219TH ANNUAL MEETING
/OL. 81— NUMBER 12— DECEMBER 1984
#2220
1 1 17
Americana
Host Farm Resort
2300 Lincoln Highway East (Route 30), Lancaster, Pennsylvania 17602 (717) 299-5500
FROM NEW YORK
Take New Jersey Turnpike
South to Pa. Turnpike. Take Pc
Turnpike West to Interchange No
21 . Travel South on U S Fite. 222
to U S. Route 30 Travel East on
U S Route 30, approximately 5
miles to Americana Host Farm
Resort
FROM PITTSBURGH
& POINTS WEST
Travel East on Pa. Turnpike to
Int. 19 Go South on 1-283 tor 30
miles into Route 30 East for 6
miles to Americana Host Farm
Resort
FROM PHILADELPHIA
Take Pa. Turnpike West to Inter-
change No. 21 . Travel South on
U S Rte. 222 to U S Route 30
Travel East on U S. Route 30, ap-
proximately 5 miles to Americana
Host Farm Resort
FROM BALTIMORE
& WASHINGTON
Go North on Interstate Route
83 to York, Pa Turn East on U S
Route 30 for 32 miles to Ameri-
cana Host Farm Resort
BY AIR
Harrisburg International Airport
(just 35 minutes from Host by lim-
ousine or car) via TWA and U S.
Air, and Lancaster Airport only
minutes away with daily flights via
U S Air.
BY RAILROAD
Amtrak to Lancaster Station.
Taxi and Rent-a-Car Service
available
1118
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
MEDICAL RESIDENT IN INTERNAL MEDICINE want-
ed for diagnosis and treatment in all areas of internal
medicine under supervision of hospital staff. Requires
M.D. degree in Medicine and one year training as a
Medical Resident; $22,785 per year; 40 hours a week.
Send resumes to Hackensack Job Service, 50 Passaic
Street, Hackensack, New Jersey 07601. J.O. #0964012
No fee charged.
CARDIOLOGIST:
Opportunity to practice cardiology with well-estab-
lished practice conveniently located to a large teaching
hospital. Duties include supervising and interpreting
Treadmills, Hotter monitors, 2D and M-Mode
Echocardiography performed in office, patient examin-
ations, hospital rounds and cardiac catheterizations.
Abilities to do streptokinase and/or angioplasty de-
sirable. Excellent beginning salary and fringe benefits.
Located in Pennsylvania.
Reply with C-V to Box No. 97, JMSNJ Immediate
Opening.
:
PRACTICE OPPORTUNITIES
\LLERGY — Suburban Philadelphia— -fully
equipped, excellent staff, and favorable
lease.
’EDIATRICS — New Jersey near NYC— very suc-
cessful practice with excellent growth record.
iNT— Pennsylvania— large, fast-growing prac-
tice. All new equipment.
VI/RHEUMATOLOGY— Arizona— well-equipped
practice in large city.
;)B/GYN— Washington State— Seller moving,
needs Buyer ASAP.
^LLERGY/IMMUNOLOGY— Close to New York
City. Good opportunity for Pediatrician/
Allergist.
or more information on these or other practice
ales or position opportunities, call (215)
67-8630 or send your Curriculum Vitae to:
HEALTH CARE
PERSONNEL CONSULTING
403 GSB Building
Bala Cynwyd, PA 19004
II —
OL. 81— NUMBER 12— DECEMBER 1984
ORTHOPEDIC SURGEON
Excellent opportunity for board eligible/certified Or-
thopedic Surgeon to replace same in medium-sized city
in progressive/rural Eastern Pennsylvania. Candidate
should have significant interest in sports medicine. Call
Judith Kennedy at 1-800-441-0996 or in PA at
215-896-5080 collect.
OBSTETRICIAN/GYNECOLOGIST
Attractive opportunity for board eligible/certified
OB/GYN to establish practice in medium-sized city in
progressive/rural Eastern Pennsylvania. Candidate
must be supportive of hospital midwifery program. Call
Judith Kennedy at 1-800-441-0996 or in PA at
215-896-5080 collect.
SPECIALISTS!
If you’re a pediatrician, OB/GYN or other medical
specialist, we need your services to complete a brand-
new, elegant, boutique-style shopping and office
center. Excellent location in upscale, affluent, growing
area. Just 5 miles from Middlesex General University
Hospital and St. Peters Medical Center. Several medi-
cal offices within center. Hidden Lake Towne Center.
Between Routes 1 and 27 in North Brunswick, New
Jersey.
For information, please call
(201) 846-5700.
1 1 19
MEDICAL PRACTICE
SALES AND APPRAISALS
We specialize in the valuation and selling of
medical practices. If interested in buying or selling
a medical practice, contact our Brokerage
Division at:
Health Care Personnel Consulting, Inc.
403 GSB Building
1 Belmont Avenue
Bala Cynwyd, PA 19004
215-667-8630
RESIDENTIAL/PROFESSIONAL
Luxury Ranch in Hartshorn location. 3 bedrooms, 3 baths. 50 foot
expanse for living and dining rooms. Den with fireplace plus 5 room
professional suite. $469,000. Call 201-467-3883. Evenings call Phyllis
Brightman at 201-376-5342.
MILLBURN/
SHORT HILLS
59 Main Street
The Sign of Experience 201-467-3883
OPHTHALMIC SURGI-CENTER AND LARGE
EYE CLINIC AVAILABLE AT ONCE.
Capacity for over 400 major and 900 minor
surgical procedures. Eye clinic capacity, 12,000
per year. Deluxe living quarters.
CALL 215-423-4477.
N.A. KARAKASHIAN, M.D.
UNIQUE BUSINESS OPPORTUNITY
FOR PHYSICIANS
American Bloodpressure Centers, Inc. is a rapidly
growing chain of hypertension treatment facilities
located in major regional shopping malls. If you
would like to explore how this sound business
growth opportunity might help you build toward
a financially secure future contact:
Richard E. Winter, M.D.
Chairman of the Board
777 Third Avenue
New York, New York 10017
212-303-1706
Don’t take
a chance
with your
career...
Emergency Physi-
cian Associates is
seeking physicians
with Emergency
Medicine, Inter-
nal Medicine and
Family Practice backgrounds who are ex-
perienced and interested in a challenging
career in Emergency Medicine.
We are currently interviewing for posi-
tions in N.J., Pa., N.Y., De. and Md.
Send your C. V. in confidence to:
James E. George, M.D.
Emergency Physician Associates
P.O. Box 298
Woodbury, N.J. 08096
Or call Donna L. Wallace, Physician
Recruitment at (609) 848-3817. E3
Need A Temporary Physician?
You can take time oft while your practice keeps working!
Lease CompHealth physicians for your vacations, CME’s
or for supplementary help.
Want Free Time While You
Practice Medicine?
Join CompHealth’s Locum Tenens Physician Group.
For further information about temporary coverage
or locum tenens practice opportunities, call:
412-741-3310
jjU CompHealth
A Physician Group
WILSON ROSS, Regional Administrator
114 Centennial Avenue
Sewickley, PA 15143
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
1120
CLASSIFIED ADVERTISEMENTS
CARDIOLOGIST/ INTERNIST NEEDED
Cardiologist needed for multi-specialty
Internal Medicine group in the South
Jersey area near Atlantic City. Salary
with eventual partnership. Excellent
benefit package. If interested please send
:urriculum vitae to Box No. 102, JMSNJ.
EMERGENCY PHYSICIAN NEEDED—
"or new urgent care center in West
Morris County. Excellent opportunity.
Reply Box No. 104, JMSNJ.
I
FAMILY PHYSICIAN /INTERNIST
NEEDED— BC/BE opportunity for per-
sonable, energetic physician in expand-
ing practice, Central New Jersey. Immedi-
ate opening or July, 1985. Send CV to
3ox No. Ill, JMSNJ.
DEEDED: GENERAL INTERNIST— Ideal
Central New Jersey practice. Position
ivailable immediately. Reply Box No. 112
IMSNJ.
NTERNIST NEEDED— To join active
hree-man pediatric practice. Fully
amished offices with lab and x-ray avail-
ble. Excellent opportunity. 201 —
84-9390.
‘HYSICIANS NEEDED— For successful
Veil known walk-in medical office center,
Central NJ. Full and part-time. Skilled
ind personable American trained MDs
end CV to E.V. McGinley, M.D., 1005 N.
Washington Avenue, Green Brook, NJ
J8812.
HYSICIANS NEEDED— New pro
:ssional office center. Ideal location for
11 specialties. X-ray and lab available,
lany extras. 201-584-9390.
HYSICIAN NEEDED— Full and part-
me physicians/general practice needed
pr new medical center in Little Falls, NJ.
all Sandy at 201-890-0855 for further
lformation.
DIAGNOSTIC RADIOLOGIST— 32 year
old Mayo Clinic trained Diagnostic
Radiologist experienced in all aspects of
Radiology seeks opportunity to practice
in New Jersey or greater Philadelphia
area Interested in locum tenens, inter-
preting all/or selected films, full or part-
time position in a clinic setting. Call
215-245-8904.
FAMILY PRACTICE— Board eligible,
ACLS certified, personable, American
graduate. Desires office/hospital work in
Central/Northem New Jersey. Please call,
if interested, 201-245-7162 or write to
218 Chestnut St., #A-6, Roselle Park, NJ
07204.
ORTHOPAEDIC SURGEON— American
graduate, trained at Downstate Medical
Center, NJ. Seeks solo, group or hospital
based position. Call 212-819-8706 dur-
ing business hours or write to Box No.
100, JMSNJ.
RADIOLOGIST — Board certified in
radiology and nuclear medicine. NJ
licensed. Teaching hospital affiliation,
desires supervision of Nuclear Medicine
with ultrasound and CT. Reply Box No.
107, JMSNJ.
RADIOLOGIST — Recently retired, BC,
very experienced, would like part-time
work; Central NJ, have car, will travel.
Write Box No. 110, JMSNJ.
RADIOLOGIST— Five years teaching
hospital base experience in Diagnostic
Radiology. Seeking to buy a well estab-
lished practice. Solo or Partnership.
Write to M.M. Bashiri, M.D., 104-20
Queens Blvd, Forest Hills, NY 11375.
FOR SALE— HOME/OFFICE— Four bed
room colonial with 800 square foot office
attached with 4 exam rooms, lab and
waiting room. Located in fastest growing
area in NJ— Marlboro, Manalapan Town-
ship. Asking $154,500. Call 201-
946-2286.
FOR SALE — Established Primary Care
Practice in Ocean County area X-ray
equipment, EKG and cardiac monitor.
Write Box No. 103, JMSNJ.
FOR SALE — Vectra camera for mam-
mary thermography. Used two years, like
new. Call 201-992-0450. Leave return
number on tape.
OFFICE SPACE — Kenilworth, NJ. Space
available for rent in medical office. Write
Box No. 109, JMSNJ.
OFFICE SPACE RENT or SHARE— New
Brunswick/Highland Park area Fur-
nished 700 square feet. Ample parking,
close to the hospital. For Rent,
$500/month plus utilities. For Share,
$300/month including utilities. Call
201-846-1661 or 201-572-7553.
OFFICE FOR RENT — Fully equipped of-
fice used for primary female care by a
husband-wife team, available at once due
to illness. Phone ringing actively by pa-
tients who want to be seen. Wonderful
opportunity to get fast start in practice
in a good town on public transportation
route. Call Jon Wilson at 201-356-6263
for particulars.
OFFICE SPACE — Chatham. Professional
offices in fine residential community.
Tri-county line, Essex, Union, Morris
Counties. Near Overlook Hospital. Now
available, call 201-635-8455 or in eve-
nings 201-992-8886.
OFFICE SPACE — Professional office for
rent in West New York. Comer location
with parking; on Doctor’s row. Close to
hospital and public transportation. Call
201-278-1000 or 201-947-4333.
OFFICE TO SHARE — Morristown, cen-
tral location. Near hospital, fully
equipped, newly decorated. All utilities
included. Ample parking available. Near
public transportation. Available immedi-
ately 201-267-2555.
OFFICE TO SHARE — Westfield, central
location, near hospital, fully equipped, at-
tractively decorated. All utilities included.
Ample parking available. Near public
transportation. Available immediately
201-233-5800.
!
’ATE INFORMATION FOR MEMBERS: $5.00 per insertion up to 25 words; 10 cents each additional word. Payable in advance.
/ORD COUNT: Count as one word all single words, two initials of a name, each abbreviation, isolated numbers, groups of
umbers, hyphenated words. Count name and address as five words, telephone number as one word, and "Write Box No. 000,
'o JMSNJ” as six words. COPY DEADLINE: Fifth of preceding month.
I
OL 81— NUMBER 12— DECEMBER 1984
1 121
Note: If you ’re new to medical practice in N. J. .
You don’t have to buy commercial
malpractice insurance
JAMES S. TODD, M.D., Chairman/Board of Directors, Medical Inter-Insurance Exchange of Newjersey
AS you made your decision to establish yourself
in New Jersey, you no doubt heard horror
stories about our professional liability insurance
problems. The legal risks we assume in this
business have grown so far out of proportion
that many commercial underwriters have been
simply unable to cope, resulting in abrupt and
often untimely suspension of coverage.
As a new practitioner in this State, either
relocating or just beginning your professional
career, you have an alternative to commercial
insurance. The Medical Inter-Insurance
Exchange provides an opportunity to build
your new practice on the most secure footing
possible with long-term peace of mind.
Founded in 1977 at the peak of the
“premium crisis,” the Exchange is a wholly
doctor-owned cooperative organization
through which we insure ourselves for our
own sake. Membership has grown to two-thirds
of all practicing physicians and surgeons in the
state. Because we’re in it for security — not
for profit — we can provide for ourselves the
absolute best available insurance product for
the money. Every dollar we take in goes toward
protection (no sales commissions) and every
dollar left over is returned to us — in cash.
You owe it to yourself to know your
options and the practicalities of each. We’re
here to help you sort them all out. Call and
talk directly to our Vice President and Director
of Policyholder Services, Bill Reilly, TOLL
FREE (in N.J.) 800-257-6288 or
(609) 896-2404 from other areas. We look
forward to hearing from you.
A professional service message from the
Medical Inter-Insurance Exchange of N.J.
Two Princess Road, Lawrenceville NJ 08648
(609) 896-2404
PHYSICIAN PROMOTE THYSELF!
*
We’re IMPACT COMMUNICATIONS and we can help you do just that. During the past six years,
we’ve pioneered the business of promoting and marketing medical practices throughout the
State. Whether your practice is small or large, established or new, we can provide you with
discreet and effective public relations and marketing services at very reasonable rates.
Our Services Include :
Broadcast interviews (TV, radio, cable)
Articles and news releases
Community speaking engagements
Advertising
Direct mail
Office brochures
Patient handouts and newsletters
Video-tape presentations
Employee communications
Call us today for an initial evaluation. We can transform your hard work into headlines!
IMPACT COMMUNICATIONS
*with apologies to Aesculapius
2033 Lemoine Avenue
Fort Lee, New Jersey 07024
(201) 947-3777
1122
THE JOURNAL OF THE MEDICAL SOCIETY OF NEW JERSEY
The Journal
of the Medical
Society of
New Jersey
JULY 1984
Transactions
1984 House of Delegates
218th Annual Meeting
May 3-6, 1984
I
The Library
Acquisitions Division
, . can Francisco
Univ. of Cant.,
San Francisco, Calif. 9 143
S
i
Transactions
1984 House of Delegates
1983 TRANSACTIONS
At its first session on May 3, 1984, the House of Delegates approved the Transactions of the 1983 House of Delegatf
as published in the July 1983, Transactions of The Journal.
ACTION TO LIMIT DEBATE
At its first session on May 3, 1984, the House of Delegates agreed, upon motion, that no one may speak more thg
once on any given subject except in rebuttal or by express permission of the House, and that floor time in eac
instance shall be limited to four minutes unless exception is made by the House.
REPORTS AND RESOLUTIONS
Reports and resolutions and the actions, thereon, are included under the Reference Committee to which they wei
assigned. The House takes action only on the resolved sections of a resolution.
THE MEDICAL SOCIETY
OF NEW JERSEY
Founded July 23, 1 7 66
Officers and Trustees
President and Chairman of the Board
Frank Y. Watson, M.D. (Essex) Glen Ridge
'President-Elect
Ralph J. Fioretti, M.D. (Bergen) Rochelle Park
First Vice-President
Edward A. Schauer, M.D. (Monmouth) Famiingdale
Second Vice-President
Harry M. Carnes, M.D. (Camden) Audubon
Immediate Past-President
Alexander D. Kovaes, M.D. (Union) Scotch Plains
Secretary
Arthur Bernstein, M.D. (Essex) South Orange
Treasurer
Paul J. Hirseh, M.D. (Somerset) Bridgewater
Trustees
Joel S. Cherashore, M.D. (1986) (Essex) Nutley
Douglas M. Costabile, M.D. (1987) (Union) Murray Hill
Palma E. Formica, M.D. (1987)
(Middlesex) New Brunswick
Harry W. Fullerton. Jr., M.D. (1985)
(Salem) Carney's Point
Frank Gingerelli, M.D. (1986) (Bergen) Hackensack
Michael M. Heeg, M.D. (1987) (Mercer) Trenton
Louis L. Keeler, M.D. (1985) (Camden) Collingswood
John P. Kengeter, M.D. (1987) (Ocean) Toms River
Edwin W. Messey, M.D. (1985) (Burlington) Willingboro
Myles C. Morrison, Jr., M.D. (1985) (Morris) .... Morristown
John J. Pastore, M.D. (1986) (Cumberland) Vineland
[Carl Restivo, Jr., M.D. (1987) (Hudson) Jersey City
(Bernard Robins, M.D. (1987) (Essex) Springfield
Gerald H. Rozan, M.D. (1987) (Passaic) Wayne
Councilors
First District
(Essex, Morris, Union, and Warren Counties)
Edward M. Coe, M.D. (1987) Cranford
Second District
(Bergen, Hudson, Passaic, and Sussex Counties)
Robert A Weinstein, M.D. (1986) Newton
Third District
(Hunterdon, Mercer, Middlesex, and Somerset Counties)
Louis G. Fares, M.D. (1985) Trenton
Fourth District
(Burlington, Camden, Monmouth, and Ocean Counties)
Frederick W. Durham, M.D. (1987) Haddonfield
Fifth District
(Atlantic, Cape May, Cumberland, Gloucester, and
Salem Counties)
Paul H. Steel, M.D. (1986) Atlantic City
AMA Delegates
William J. D’Elia M.D., Chairman (1985) Spring Lake
[Alfred A. Alessi, M.D. (1986) Hackensack
-Frederick W. Durham, M.D. (1986) Haddonfield
Palma E. Formica M.D. (1986) New Brunswick
Karl T. Franzoni, M.D. (1986) Trenton
John S. Madara M.D. (1986) Salem
'Henry J. Mineur, M.D. (1986) Cranford
[Myles C. Morrison, Jr., M.D. (1985) Morristown
Howard D. Slobodien, M.D. (1985) Metuchen
AMA Trustee
James S. Todd, M.D. (Ridgewood) Bergen
July Transactions 1984
Publication Committee
Paul J. Hirseh, M.D., Chairman
Dirck L. Brendlinger, M.D.
Frederick B. Cohen, M.D.
A. Olusegun Fayemi, M.D.
Robert M. MacMillan, M.D.
Leon G. Smith, M.D.
La Verne Fioretti
Editor
Arthur Krosnick, M.D.
Managing Editor
Geraldine R Hutner
Assistant Managing Editor
Dorothy J. Griffith
Advertising Manager
E. Elizabeth Cookson
Executive Director
Vincent A. Maressa
Executive Director Emeritus
Richard I. Nevin
Editorial Board
Jerome Abrams, M.D. (Obstet/Gynecol)
Joseph Alpert, M.D. (Vase Surg)
Harold Arlen, M.D. (Otolaryngol)
Alfonse Cinotti, M.D. (Ophthalmol)
Robert Dodelson, M.D. (Nephrol)
Norman H. Ertel, M.D. (Int Med/Endocrinol)
Daniel P. Greenfield, M.D. (Psychiat)
Christine E. Haycock M.D. (Sports Med)
Monroe S. Karetzky, M.D. (Pulmon Med)
Avrum L. Katcher, M.D. (Pediatr)
Stanley C. Leonberg, Jr., M.D. (Neurol)
Joel D. Levinson, M.D. (Gastroenterol)
Joseph A Lieberman, III, M.D. (Fam Med)
Henry R Liss, M.D. (Neurosurg)
Geobel A Marin, M.D. (Int Med/Gastroenterol)
Donald G. McKaba M.D. (Allergy)
Robby Meijer, M.D. (Plas Surg)
Frank T. Padberg, Jr., M.D. (Surg)
Christopher A. Papa M.D. (Dermatol)
Norman Riegel, M.D. (Book Review)
Edwin L. Rothfield, M.D. (Cardiol)
Benjamin F. Rush, Jr., M.D. (Surg)
Morris H. Saffron, M.D. (Med His)
Mark M. Singer. M.D. (Int Med/Endocrinol)
Sheldon D. Solomon, M.D. (Rheum)
Lloyd N. Spindell. M.D. (Radiol)
A. Arthur Sugerman, M.D. (Psychiat)
Stephen F. Wang, M.D. (Pediatr)
Edwin S. Wilson, M.D. (Radiol)
Louis S. Zeiger, M.D. (Nucl Med)
Robert B. Zufall, M.D. (Urol)
'he Journal of the Medical Society of New Jersey (ISSN-0025-7524) is published monthly (since 1904) except
emimonthly in July (13 issues), under direction of the Committee on Publication, by (he Medical Society of New
ersey. Two Princess Road, Lawreneeville, NJ 08648. Printed in East Stroudsburg, PA, by (lie Hughes 
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